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The Mediterranean diet appears to be associated with a lower incidence of cardiovascular disease (CVD) and mortality in women, new observational data suggest.

Those who had a higher adherence to a Mediterranean diet had a 24% lower risk for cardiovascular disease and 23% lower risk for death.

“A healthy diet is a huge factor in preventing heart disease. However, current guidelines on preventing heart disease lack sex-specific recommendations,” said senior author Sarah Zaman, MBBS, PhD, an associate professor of medicine and principal research fellow at the University of Sydney’s Westmead Applied Research Centre.

snyferok/Thinkstock

Analyzing cardiovascular outcomes

Dr. Zaman and colleagues conducted a systematic review and meta-analysis of 16 studies published between 2006 and 2021 that reported a Mediterranean diet score and included either all women or had stratified outcomes by sex. They excluded studies that referred to only certain components of the Mediterranean diet or combined it with other lifestyle-related factors.

The studies, which were mainly conducted in the United States and Europe, included 722,495 adult women without previous clinical or subclinical CVD, with a median follow-up of 12.5 years.

Higher Mediterranean diet adherence was defined as the highest category reporting the highest range of Mediterranean diet scores, and lower adherence was defined as the lowest category reporting lowest scores. Incident CVD included coronary heart disease, myocardial infarction, stroke, heart failure, cardiovascular death, major adverse cardiovascular events, major adverse cardiac cerebrovascular events, and patient-reported CVD.

Overall, higher adherence to a Mediterranean diet was associated with lower CVD incidence (hazard ratio, 0.76; 95% confidence interval, 0.72-0.81), total mortality (HR, 0.77; 95% CI, 0.74-0.80), and coronary heart disease (HR, 0.75; 95% CI, 0.65-0.87).

Stroke incidence was also lower among women who adhered to the Mediterranean diet, although it wasn’t considered statistically significant (HR, 0.87; 95% CI, 0.76-1.01).

Additional analyses found similar reductions in risk across women of different ethnicities. Higher Mediterranean diet adherence was associated with lower CVD incidence for both women of European descent (HR, 0.76; 95% CI, 0.59-0.98) and women of non-European descent – Asian, Native Hawaiian, and African American – (HR, 0.79; 95% CI, 0.72-0.87).

The results didn’t materially change in sensitivity analyses, the authors note. Excluding one study at a time, the pooled HRs for the highest versus the lowest Mediterranean diet adherence ranged from 0.76 (95% CI, 0.72-0.80) to 0.83 (95% CI, 0.70-0.98) for incident CVD and from 0.77 (95% CI, 0.75-0.80) to 0.77 (95% CI, 0.74-0.81) for total mortality among women.

At the same time, the authors pointed to several limitations, including the observational nature of all of the studies, the reliance on self-reported food frequency questionnaires, and heterogeneity in the adjustments for influential factors across the studies.
 

Additional considerations

Dr. Zaman and colleagues called for more sex-specific research in cardiology, including risk factors related to premature menopause, preeclampsia, gestational diabetes, and autoimmune diseases such as systemic lupus.

Future studies should also explore the underlying mechanisms that may explain the links between the Mediterranean diet, cardiovascular disease, and death, the authors write. For instance, the diet may reduce inflammation and cardiovascular risk factors through antioxidant and beneficial gut microbiome pathways. Other components of the diet – such as polyphenols, nitrates, omega-3 fatty acids, higher fiber intake, and reduced glycemic load – may also play a role.

“It was striking to see how strong the long-term cardioprotective properties of a Mediterranean-type dietary pattern were,” said Samia Mora, MD, MHS, a professor of medicine at Harvard Medical School and director of the Center for Lipid Metabolomics at Brigham and Women’s Hospital.

Dr. Mora, who wasn’t involved with this study, has researched potential mechanisms related to the Mediterranean diet, cardiovascular events, and diabetes in women. She and colleagues have found that women with high adherence to the diet are more likely to have lower inflammation, insulin resistance, body mass index, and blood pressure, as well as improved lipid and metabolic profiles.

“This could represent an opportunity to intervene earlier and more intensively on improving inflammation, insulin resistance, and cardiometabolic health through evidence-based dietary approaches such as the Mediterranean diet,” she said. “As health care providers, we should promote the healthy dietary attributes of the Mediterranean diet, especially as many of our patients in the U.S. are less familiar with the Mediterranean diet and how to incorporate its components into daily food intake.”

The study did not receive any funding. Dr. Zaman was supported by a Heart Foundation Future Leader Fellowship. The authors declared no conflicts of interest. Dr. Mora reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Mediterranean diet appears to be associated with a lower incidence of cardiovascular disease (CVD) and mortality in women, new observational data suggest.

Those who had a higher adherence to a Mediterranean diet had a 24% lower risk for cardiovascular disease and 23% lower risk for death.

“A healthy diet is a huge factor in preventing heart disease. However, current guidelines on preventing heart disease lack sex-specific recommendations,” said senior author Sarah Zaman, MBBS, PhD, an associate professor of medicine and principal research fellow at the University of Sydney’s Westmead Applied Research Centre.

snyferok/Thinkstock

Analyzing cardiovascular outcomes

Dr. Zaman and colleagues conducted a systematic review and meta-analysis of 16 studies published between 2006 and 2021 that reported a Mediterranean diet score and included either all women or had stratified outcomes by sex. They excluded studies that referred to only certain components of the Mediterranean diet or combined it with other lifestyle-related factors.

The studies, which were mainly conducted in the United States and Europe, included 722,495 adult women without previous clinical or subclinical CVD, with a median follow-up of 12.5 years.

Higher Mediterranean diet adherence was defined as the highest category reporting the highest range of Mediterranean diet scores, and lower adherence was defined as the lowest category reporting lowest scores. Incident CVD included coronary heart disease, myocardial infarction, stroke, heart failure, cardiovascular death, major adverse cardiovascular events, major adverse cardiac cerebrovascular events, and patient-reported CVD.

Overall, higher adherence to a Mediterranean diet was associated with lower CVD incidence (hazard ratio, 0.76; 95% confidence interval, 0.72-0.81), total mortality (HR, 0.77; 95% CI, 0.74-0.80), and coronary heart disease (HR, 0.75; 95% CI, 0.65-0.87).

Stroke incidence was also lower among women who adhered to the Mediterranean diet, although it wasn’t considered statistically significant (HR, 0.87; 95% CI, 0.76-1.01).

Additional analyses found similar reductions in risk across women of different ethnicities. Higher Mediterranean diet adherence was associated with lower CVD incidence for both women of European descent (HR, 0.76; 95% CI, 0.59-0.98) and women of non-European descent – Asian, Native Hawaiian, and African American – (HR, 0.79; 95% CI, 0.72-0.87).

The results didn’t materially change in sensitivity analyses, the authors note. Excluding one study at a time, the pooled HRs for the highest versus the lowest Mediterranean diet adherence ranged from 0.76 (95% CI, 0.72-0.80) to 0.83 (95% CI, 0.70-0.98) for incident CVD and from 0.77 (95% CI, 0.75-0.80) to 0.77 (95% CI, 0.74-0.81) for total mortality among women.

At the same time, the authors pointed to several limitations, including the observational nature of all of the studies, the reliance on self-reported food frequency questionnaires, and heterogeneity in the adjustments for influential factors across the studies.
 

Additional considerations

Dr. Zaman and colleagues called for more sex-specific research in cardiology, including risk factors related to premature menopause, preeclampsia, gestational diabetes, and autoimmune diseases such as systemic lupus.

Future studies should also explore the underlying mechanisms that may explain the links between the Mediterranean diet, cardiovascular disease, and death, the authors write. For instance, the diet may reduce inflammation and cardiovascular risk factors through antioxidant and beneficial gut microbiome pathways. Other components of the diet – such as polyphenols, nitrates, omega-3 fatty acids, higher fiber intake, and reduced glycemic load – may also play a role.

“It was striking to see how strong the long-term cardioprotective properties of a Mediterranean-type dietary pattern were,” said Samia Mora, MD, MHS, a professor of medicine at Harvard Medical School and director of the Center for Lipid Metabolomics at Brigham and Women’s Hospital.

Dr. Mora, who wasn’t involved with this study, has researched potential mechanisms related to the Mediterranean diet, cardiovascular events, and diabetes in women. She and colleagues have found that women with high adherence to the diet are more likely to have lower inflammation, insulin resistance, body mass index, and blood pressure, as well as improved lipid and metabolic profiles.

“This could represent an opportunity to intervene earlier and more intensively on improving inflammation, insulin resistance, and cardiometabolic health through evidence-based dietary approaches such as the Mediterranean diet,” she said. “As health care providers, we should promote the healthy dietary attributes of the Mediterranean diet, especially as many of our patients in the U.S. are less familiar with the Mediterranean diet and how to incorporate its components into daily food intake.”

The study did not receive any funding. Dr. Zaman was supported by a Heart Foundation Future Leader Fellowship. The authors declared no conflicts of interest. Dr. Mora reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Mediterranean diet appears to be associated with a lower incidence of cardiovascular disease (CVD) and mortality in women, new observational data suggest.

Those who had a higher adherence to a Mediterranean diet had a 24% lower risk for cardiovascular disease and 23% lower risk for death.

“A healthy diet is a huge factor in preventing heart disease. However, current guidelines on preventing heart disease lack sex-specific recommendations,” said senior author Sarah Zaman, MBBS, PhD, an associate professor of medicine and principal research fellow at the University of Sydney’s Westmead Applied Research Centre.

snyferok/Thinkstock

Analyzing cardiovascular outcomes

Dr. Zaman and colleagues conducted a systematic review and meta-analysis of 16 studies published between 2006 and 2021 that reported a Mediterranean diet score and included either all women or had stratified outcomes by sex. They excluded studies that referred to only certain components of the Mediterranean diet or combined it with other lifestyle-related factors.

The studies, which were mainly conducted in the United States and Europe, included 722,495 adult women without previous clinical or subclinical CVD, with a median follow-up of 12.5 years.

Higher Mediterranean diet adherence was defined as the highest category reporting the highest range of Mediterranean diet scores, and lower adherence was defined as the lowest category reporting lowest scores. Incident CVD included coronary heart disease, myocardial infarction, stroke, heart failure, cardiovascular death, major adverse cardiovascular events, major adverse cardiac cerebrovascular events, and patient-reported CVD.

Overall, higher adherence to a Mediterranean diet was associated with lower CVD incidence (hazard ratio, 0.76; 95% confidence interval, 0.72-0.81), total mortality (HR, 0.77; 95% CI, 0.74-0.80), and coronary heart disease (HR, 0.75; 95% CI, 0.65-0.87).

Stroke incidence was also lower among women who adhered to the Mediterranean diet, although it wasn’t considered statistically significant (HR, 0.87; 95% CI, 0.76-1.01).

Additional analyses found similar reductions in risk across women of different ethnicities. Higher Mediterranean diet adherence was associated with lower CVD incidence for both women of European descent (HR, 0.76; 95% CI, 0.59-0.98) and women of non-European descent – Asian, Native Hawaiian, and African American – (HR, 0.79; 95% CI, 0.72-0.87).

The results didn’t materially change in sensitivity analyses, the authors note. Excluding one study at a time, the pooled HRs for the highest versus the lowest Mediterranean diet adherence ranged from 0.76 (95% CI, 0.72-0.80) to 0.83 (95% CI, 0.70-0.98) for incident CVD and from 0.77 (95% CI, 0.75-0.80) to 0.77 (95% CI, 0.74-0.81) for total mortality among women.

At the same time, the authors pointed to several limitations, including the observational nature of all of the studies, the reliance on self-reported food frequency questionnaires, and heterogeneity in the adjustments for influential factors across the studies.
 

Additional considerations

Dr. Zaman and colleagues called for more sex-specific research in cardiology, including risk factors related to premature menopause, preeclampsia, gestational diabetes, and autoimmune diseases such as systemic lupus.

Future studies should also explore the underlying mechanisms that may explain the links between the Mediterranean diet, cardiovascular disease, and death, the authors write. For instance, the diet may reduce inflammation and cardiovascular risk factors through antioxidant and beneficial gut microbiome pathways. Other components of the diet – such as polyphenols, nitrates, omega-3 fatty acids, higher fiber intake, and reduced glycemic load – may also play a role.

“It was striking to see how strong the long-term cardioprotective properties of a Mediterranean-type dietary pattern were,” said Samia Mora, MD, MHS, a professor of medicine at Harvard Medical School and director of the Center for Lipid Metabolomics at Brigham and Women’s Hospital.

Dr. Mora, who wasn’t involved with this study, has researched potential mechanisms related to the Mediterranean diet, cardiovascular events, and diabetes in women. She and colleagues have found that women with high adherence to the diet are more likely to have lower inflammation, insulin resistance, body mass index, and blood pressure, as well as improved lipid and metabolic profiles.

“This could represent an opportunity to intervene earlier and more intensively on improving inflammation, insulin resistance, and cardiometabolic health through evidence-based dietary approaches such as the Mediterranean diet,” she said. “As health care providers, we should promote the healthy dietary attributes of the Mediterranean diet, especially as many of our patients in the U.S. are less familiar with the Mediterranean diet and how to incorporate its components into daily food intake.”

The study did not receive any funding. Dr. Zaman was supported by a Heart Foundation Future Leader Fellowship. The authors declared no conflicts of interest. Dr. Mora reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Air pollution appears to contribute independently to bone damage in postmenopausal women, new data suggest.

The findings come from a new analysis of data from the Women’s Health Initiative (WHI) and location-specific air particulate information from the U.S. Environmental Protection Agency.

copyright Sergiy Serdyuk/istockphoto.com

“Our findings confirm that poor air quality may be a risk factor for bone loss, independent of socioeconomic or demographic factors, and expands previous findings to postmenopausal women. Indeed, to our knowledge, this is the first study of the impact of criteria air pollutants on bone health in postmenopausal women,” Diddier Prada, MD, PhD, Columbia University, New York, and colleagues wrote.

The results are also the first to show that “nitrogen oxides contribute the most to bone damage and that the lumbar spine is one of the most susceptible sites,” they added.

Public health policies should aim to reduce air pollution in general, they wrote, and reducing nitrogen oxides, in particular, will reduce bone damage in postmenopausal women, prevent bone fractures, and reduce the health cost burden associated with osteoporosis in this population.

The findings were recently published in eClinicalMedicine.

Asked to comment, Giovanni Adami, MD, PhD, said in an interview that the study “adds to the body of literature on air pollution and bone health. The study confirms and provides further evidence linking air pollution exposure and osteoporosis.”

Dr. Adami, of the University of Verona (Italy), who also studies this topic, said that these new findings align with those from his group and others.

“The scientific literature in the field is clearly pointing toward a negative effect of chronic pollution exposure on bone health.”

He pointed to one study from his group that found chronic exposure to ultrafine particulate matter is associated with low BMD, and consequently, bone fragility, and another study that showed acute exposure to high levels of pollutants could actually cause fractures.

As for what might be done clinically, Dr. Adami said: “It is difficult to extrapolate direct and immediate recommendations for patients.

“However, it might be acceptable to say that patients at risk of osteoporosis, such as older women or those with prior bone fractures, should avoid chronic exposure to air pollution, perhaps using masks when walking in traffic or using air filters for indoor ventilation.”

Dr. Adami also said that this evidence so far might spur the future inclusion of chronic exposure to air pollution in fracture risk assessment tools, although this isn’t likely to come about in the near future.
 

Particulates linked to whole-body, hip, lumbar, and femoral neck BMD

The prospective observational study included 9,041 WHI participants seen over 32,663 visits who were an average of 63 years old at baseline. More than 70% were White, and just under half were college graduates.

With geocoded address data used to estimate particulate matter concentrations, mean levels of particulate matter of 10 mcm or less, nitrogen oxide nitrogen dioxide, and sulfur dioxide over 1, 3, and 5 years were all negatively associated with whole-body, total hip, femoral neck, and lumbar spine BMD.

In the multivariate analysis, the highest correlations were found between nitrogen oxide and nitrogen dioxide. For example, lumbar spine BMD decreased by 0.026 g/cm² per year per 10% increase in 3-year mean nitrogen dioxide concentration.

“Our findings show that both particulate matter and gases may adversely impact BMD and that nitrogen oxides may play a critical role in bone damage and osteoporosis risk,” Dr. Prada and colleagues wrote.

Dr. Adami added: “We need more data to understand the precise magnitude of effect of air pollution on fractures, which might depend on levels of exposure but also on genetics and lifestyle.”

The study was funded by the National Institutes of Health. The authors reported no relevant financial relationships. Dr. Adami reported receiving fees from Amgen, Eli Lilly, UCB, Fresenius Kabi, Galapagos, and Theramex.

A version of this article originally appeared on Medscape.com.

Air pollution appears to contribute independently to bone damage in postmenopausal women, new data suggest.

The findings come from a new analysis of data from the Women’s Health Initiative (WHI) and location-specific air particulate information from the U.S. Environmental Protection Agency.

copyright Sergiy Serdyuk/istockphoto.com

“Our findings confirm that poor air quality may be a risk factor for bone loss, independent of socioeconomic or demographic factors, and expands previous findings to postmenopausal women. Indeed, to our knowledge, this is the first study of the impact of criteria air pollutants on bone health in postmenopausal women,” Diddier Prada, MD, PhD, Columbia University, New York, and colleagues wrote.

The results are also the first to show that “nitrogen oxides contribute the most to bone damage and that the lumbar spine is one of the most susceptible sites,” they added.

Public health policies should aim to reduce air pollution in general, they wrote, and reducing nitrogen oxides, in particular, will reduce bone damage in postmenopausal women, prevent bone fractures, and reduce the health cost burden associated with osteoporosis in this population.

The findings were recently published in eClinicalMedicine.

Asked to comment, Giovanni Adami, MD, PhD, said in an interview that the study “adds to the body of literature on air pollution and bone health. The study confirms and provides further evidence linking air pollution exposure and osteoporosis.”

Dr. Adami, of the University of Verona (Italy), who also studies this topic, said that these new findings align with those from his group and others.

“The scientific literature in the field is clearly pointing toward a negative effect of chronic pollution exposure on bone health.”

He pointed to one study from his group that found chronic exposure to ultrafine particulate matter is associated with low BMD, and consequently, bone fragility, and another study that showed acute exposure to high levels of pollutants could actually cause fractures.

As for what might be done clinically, Dr. Adami said: “It is difficult to extrapolate direct and immediate recommendations for patients.

“However, it might be acceptable to say that patients at risk of osteoporosis, such as older women or those with prior bone fractures, should avoid chronic exposure to air pollution, perhaps using masks when walking in traffic or using air filters for indoor ventilation.”

Dr. Adami also said that this evidence so far might spur the future inclusion of chronic exposure to air pollution in fracture risk assessment tools, although this isn’t likely to come about in the near future.
 

Particulates linked to whole-body, hip, lumbar, and femoral neck BMD

The prospective observational study included 9,041 WHI participants seen over 32,663 visits who were an average of 63 years old at baseline. More than 70% were White, and just under half were college graduates.

With geocoded address data used to estimate particulate matter concentrations, mean levels of particulate matter of 10 mcm or less, nitrogen oxide nitrogen dioxide, and sulfur dioxide over 1, 3, and 5 years were all negatively associated with whole-body, total hip, femoral neck, and lumbar spine BMD.

In the multivariate analysis, the highest correlations were found between nitrogen oxide and nitrogen dioxide. For example, lumbar spine BMD decreased by 0.026 g/cm² per year per 10% increase in 3-year mean nitrogen dioxide concentration.

“Our findings show that both particulate matter and gases may adversely impact BMD and that nitrogen oxides may play a critical role in bone damage and osteoporosis risk,” Dr. Prada and colleagues wrote.

Dr. Adami added: “We need more data to understand the precise magnitude of effect of air pollution on fractures, which might depend on levels of exposure but also on genetics and lifestyle.”

The study was funded by the National Institutes of Health. The authors reported no relevant financial relationships. Dr. Adami reported receiving fees from Amgen, Eli Lilly, UCB, Fresenius Kabi, Galapagos, and Theramex.

A version of this article originally appeared on Medscape.com.

Air pollution appears to contribute independently to bone damage in postmenopausal women, new data suggest.

The findings come from a new analysis of data from the Women’s Health Initiative (WHI) and location-specific air particulate information from the U.S. Environmental Protection Agency.

copyright Sergiy Serdyuk/istockphoto.com

“Our findings confirm that poor air quality may be a risk factor for bone loss, independent of socioeconomic or demographic factors, and expands previous findings to postmenopausal women. Indeed, to our knowledge, this is the first study of the impact of criteria air pollutants on bone health in postmenopausal women,” Diddier Prada, MD, PhD, Columbia University, New York, and colleagues wrote.

The results are also the first to show that “nitrogen oxides contribute the most to bone damage and that the lumbar spine is one of the most susceptible sites,” they added.

Public health policies should aim to reduce air pollution in general, they wrote, and reducing nitrogen oxides, in particular, will reduce bone damage in postmenopausal women, prevent bone fractures, and reduce the health cost burden associated with osteoporosis in this population.

The findings were recently published in eClinicalMedicine.

Asked to comment, Giovanni Adami, MD, PhD, said in an interview that the study “adds to the body of literature on air pollution and bone health. The study confirms and provides further evidence linking air pollution exposure and osteoporosis.”

Dr. Adami, of the University of Verona (Italy), who also studies this topic, said that these new findings align with those from his group and others.

“The scientific literature in the field is clearly pointing toward a negative effect of chronic pollution exposure on bone health.”

He pointed to one study from his group that found chronic exposure to ultrafine particulate matter is associated with low BMD, and consequently, bone fragility, and another study that showed acute exposure to high levels of pollutants could actually cause fractures.

As for what might be done clinically, Dr. Adami said: “It is difficult to extrapolate direct and immediate recommendations for patients.

“However, it might be acceptable to say that patients at risk of osteoporosis, such as older women or those with prior bone fractures, should avoid chronic exposure to air pollution, perhaps using masks when walking in traffic or using air filters for indoor ventilation.”

Dr. Adami also said that this evidence so far might spur the future inclusion of chronic exposure to air pollution in fracture risk assessment tools, although this isn’t likely to come about in the near future.
 

Particulates linked to whole-body, hip, lumbar, and femoral neck BMD

The prospective observational study included 9,041 WHI participants seen over 32,663 visits who were an average of 63 years old at baseline. More than 70% were White, and just under half were college graduates.

With geocoded address data used to estimate particulate matter concentrations, mean levels of particulate matter of 10 mcm or less, nitrogen oxide nitrogen dioxide, and sulfur dioxide over 1, 3, and 5 years were all negatively associated with whole-body, total hip, femoral neck, and lumbar spine BMD.

In the multivariate analysis, the highest correlations were found between nitrogen oxide and nitrogen dioxide. For example, lumbar spine BMD decreased by 0.026 g/cm² per year per 10% increase in 3-year mean nitrogen dioxide concentration.

“Our findings show that both particulate matter and gases may adversely impact BMD and that nitrogen oxides may play a critical role in bone damage and osteoporosis risk,” Dr. Prada and colleagues wrote.

Dr. Adami added: “We need more data to understand the precise magnitude of effect of air pollution on fractures, which might depend on levels of exposure but also on genetics and lifestyle.”

The study was funded by the National Institutes of Health. The authors reported no relevant financial relationships. Dr. Adami reported receiving fees from Amgen, Eli Lilly, UCB, Fresenius Kabi, Galapagos, and Theramex.

A version of this article originally appeared on Medscape.com.

Baily Nagle, vice president of her graduating class at Harvard Medical School, Boston, celebrated “the luck of the Irish” on St. Patrick’s Day that allowed her to match into her chosen specialty and top choice of residency programs: anesthesia at Brigham and Women’s Hospital.

“I am feeling very excited and relieved – I matched,” she said in an interview upon hearing her good fortune on Match Monday, March 13. She had a similar reaction on Match Day, March 17. “After a lot of long nights and hard work, happy to have it pay off.”

Ms. Nagle was so determined to match into her specialty that she didn’t have any other specialties in mind as a backup.

The annual process of matching medical school graduates with compatible residency programs is an emotional roller coaster for all applicants, their personal March Madness, so to speak. But Ms. Nagle was one of the more fortunate applicants. She didn’t have to confront the heartbreak other applicants felt when the National Resident Matching Program (NRMP) announced results of the main residency match and the Supplemental Offer and Acceptance Program (SOAP), which offers alternate programs for unfilled positions or unmatched applicants.

During the 2023 Match process, this news organization has been following a handful of students, checking in with them periodically for updates on their progress. Most of them matched successfully, but at least one international medical graduate (IMG) did not. What the others have in common is that their hearts were set on a chosen specialty. Like Ms. Nagle, another student banked on landing his chosen specialty without a backup plan, whereas another said that she’d continue through the SOAP if she didn’t match successfully.

Overall, Match Day resulted in a record number of residency positions offered, most notably in primary care, which “hit an all-time high,” according to NRMP President and CEO Donna L. Lamb, DHSc, MBA, BSN. The number of positions has “consistently increased over the past 5 years, and most importantly the fill rate for primary care has remained steady,” Dr.. Lamb noted in the NRMP release of Match Day results. The release coincided with students learning through emails at noon Eastern Time to which residency or supplemental programs they were matched.

Though more applicants registered for the Match in 2023 than in 2022 – driven primarily by non-U.S. IMGs – the NRMP stated that it was surprised by the decrease in U.S. MD senior applicants.

U.S. MD seniors had a nearly 94% Match rate, a small increase over 2022. U.S. citizen IMGs saw a nearly 68% Match rate, which NRMP reported as an “all-time high” and about six percentage points over in 2022, whereas non-U.S. IMGs had a nearly 60% Match rate, a 1.3 percentage point increase over 2022.

Among the specialties that filled all available positions in 2023 were orthopedic surgery, plastic surgery (integrated), and radiology – diagnostic and thoracic surgery.
 

Not everyone matches

On March 13, the American College of Emergency Physicians issued a joint statement with other emergency medicine (EM) organizations about a high rate of unfilled EM positions expected in 2023.

NRMP acknowledged March 17 that 554 positions remained unfilled, an increase of 335 more unfilled positions than 2022. NRMP attributed the increase in unfilled positions in part to a decrease in the number of U.S. MD and U.S. DO seniors who submitted ranks for the specialty, which “could reflect changing applicant interests or projections about workforce opportunities post residency.”

Applicants who didn’t match usually try to obtain an unfilled position through SOAP. In 2023, 2,685 positions were unfilled after the matching algorithm was processed, an increase of nearly 19% over 2022. The vast majority of those positions were placed in SOAP, an increase of 17.5% over 2022.

Asim Ansari was one of the unlucky ones. Mr. Ansari was trying to match for the fifth time. He was unsuccessful in doing so again in 2023 in the Match and SOAP. Still, he was offered and accepted a child and adolescent psychiatry fellowship at Kansas University Medical Center in Kansas City. Psychiatry was his chosen specialty, so he was “feeling good. It’s a nice place to go to do the next 2 years.”

Mr. Ansari, who started the #MatchMadness support group for unmatched doctors on Twitter Spaces, was quick to cheer on his fellow matching peers on March 13 while revealing his own fate: “Congratulations to everyone who matched!!! Y’all are amazing. So proud of each one of you!!! I didn’t.”

Soon after the results, #MatchMadness held a #Soap2023 support session, and Mr. Ansari sought advice for those willing to review SOAP applications. Elsewhere on Twitter Match Day threads, a few doctors offered their support to those who planned to SOAP, students announced their matches, and others either congratulated or encouraged those still trying to match.
 

Couples match

Not everyone who matched considered the alternative. Before March 13, William Boyer said that he hadn’t given much thought to what would happen if he didn’t match because he was “optimistically confident” he would match into his chosen EM specialty. But he did and got his top choice of programs: Yale New Haven (Conn.) Hospital.

“I feel great,” he said in an interview. “I was definitely nervous opening the envelope” that revealed his residency program, “but there was a rush of relief” when he saw he landed Yale.

Earlier in the match cycle, he said in an interview that he “interviewed at a few ‘reach’ programs, so I hope I don’t match lower than expected on my rank list.”

Mr. Boyer considers himself “a mature applicant,” entering the University of South Carolina, Columbia, after 4 years as an insurance broker.

“I am celebrating today by playing pickleball with a few close medical friends who also matched this morning,” Mr. Boyer said on March 13. “I definitely had periods of nervousness leading up to this morning though that quickly turned into joy and relief” after learning he matched.

Mr. Boyer believes that his professional experience in the insurance industry and health care lobbying efforts with the National Association of Health Underwriters set him apart from other applicants.

“I changed careers to pursue this aspiration, which demonstrates my full dedication to the medical profession.”

He applied to 48 programs and was offered interviews to nearly half. Mr. Boyer visited the majority of those virtually. He said he targeted programs close to where his and his partner’s families are located: Massachusetts, North Carolina, and Texas. “My partner, who I met in medical school, matched into ortho as well so the whole household is very happy,” Mr. Boyer said.

She matched into her top choice as well on March 17, though a distance away at UT Health in San Antonio, he said. “We are both ecstatic. We both got our no. 1 choice. That was the plan going into it. We will make it work. I have 4 weeks of vacation.”

In his program choices, Mr. Boyer prioritized access to nature, minimal leadership turnover, a mix of clinical training sites, and adequate elective rotations and fellowship opportunities, such as in wilderness medicine and health policy.

NRMP reported that there were 1,239 couples participating in the Match; 1,095 had both partners match, and 114 had one partner match to residency training programs for a match rate of 93%.

Like Mr. Boyer, Hannah Hedriana matched into EM, one of the more popular despite the reported unfilled positions. In the past few years, it has consistently been one of the fastest-growing specialties, according to the NRMP.

Still Ms. Hedriana had a fall-back plan. “If I don’t match, then I do plan on going through SOAP. With the number of EM spots that were unfilled in 2022, there’s a chance I could still be an EM physician, but if not, then that’s okay with me.”

Her reaction on March 13, after learning she matched? “Super excited, celebrating with my friends right now.” On Match Day, she said she was “ecstatic” to be matched into Lakeland (Fla.) Regional Health. “This was my first choice so now I can stay close to family and friends,” she said in an interview soon after the results were released.

A first-generation, Filipino American student from the University of South Florida, Tampa, Ms. Hedriana comes from a family of health care professionals. Her father is a respiratory therapist turned physical therapist; her mother a registered nurse. Her sister is a patient care technician applying to nursing school.

Ms. Hedriana applied to 70 programs and interviewed mostly online with 24. Her goal was to stay on the East Coast.

“My partner is a licensed dentist in the state of Florida, and so for his career it would be more practical to stay in state, rather than get relicensed in another state, which could take months,” she said earlier in the matching cycle. “However, when we discussed choosing a residency program, he ultimately left it up to me and wanted me to pick where I thought I’d flourish best,” Ms. Hedriana said, adding that her family lives in Florida, too.

She said she sought a residency program that values family and teamwork.

“A program gets more points in my book if they have sites at nonprofit hospitals or has residents that regularly volunteer throughout their communities or participate in DEI [diversity, equity, and inclusion] initiatives.”

Ms. Hedriana noted that some specialties exclusively offered virtual interviews in 2023, whereas other specialties favored in-person interviews. “This year, many of my classmates were able to do multiple away rotations, which they saw as a positive regarding their chances of matching.” During COVID, in-person visits were limited.

“However, I’ve noticed that many of my classmates are not fond of the signaling aspect that was present for this year’s cycle,” she said. Signaling is a relatively new process that allows applicants to indicate interest in a limited number of residency programs. Not all residencies participate, but it’s growing in popularity among specialties, according to the American Medical Association.
 

‘Extremely competitive’

Ms. Nagle, a second lieutenant in the U.S. Air Force, applied to 12 programs and interviewed with half of them online. She said that she wasn’t targeting any specific type of program through the match.

“I believe you can get phenomenal training anywhere where you mesh with the residents and leadership. My ultimate priority is to (1) be near good people, (2) be near good food (Indian and Thai are a must), and (3) be near an international airport so I can flee the country during breaks.”

Meanwhile, she said that she found the application process, in which students have to articulate their entire medical school experience, extremely competitive. “I think this process is so easy to get wound up in and the anxiety can be palpable,” Ms. Nagle said. “People around you match your energy. So if you are a ball of anxiety then so are your attendings and residents – and that doesn’t bode well for passing the ‘do I want to be on call with them’ test.”

Looking back at medical school, Ms. Nagle recalled having a baby named after her during her first anesthesia rotation and being featured on The Kelly Clarkson Show. Ms. Nagle said that she had walked into the delivery room where new parents had been debating names of babies beginning with the letter B. “And when I introduced myself, they looked at each other and said, ‘Yep, that’s the one.’”

Mr. Boyer recounted how the majority of his medical school experience involved online education. “Roughly two-thirds of my first year was in-person prior to the pandemic. However, from spring break first year to in-person clinical rotations at the beginning of third year, we were all virtual. While I missed interacting with my classmates, I benefited from the virtual learning environment as I learn more efficiently from reading and visual aids than auditory lectures.”

Ms. Hedriana cited the friends and memories she made while learning to be a doctor. “Medical school was hard, but I wouldn’t have changed a thing.”

A version of this article first appeared on Medscape.com.

Baily Nagle, vice president of her graduating class at Harvard Medical School, Boston, celebrated “the luck of the Irish” on St. Patrick’s Day that allowed her to match into her chosen specialty and top choice of residency programs: anesthesia at Brigham and Women’s Hospital.

“I am feeling very excited and relieved – I matched,” she said in an interview upon hearing her good fortune on Match Monday, March 13. She had a similar reaction on Match Day, March 17. “After a lot of long nights and hard work, happy to have it pay off.”

Ms. Nagle was so determined to match into her specialty that she didn’t have any other specialties in mind as a backup.

The annual process of matching medical school graduates with compatible residency programs is an emotional roller coaster for all applicants, their personal March Madness, so to speak. But Ms. Nagle was one of the more fortunate applicants. She didn’t have to confront the heartbreak other applicants felt when the National Resident Matching Program (NRMP) announced results of the main residency match and the Supplemental Offer and Acceptance Program (SOAP), which offers alternate programs for unfilled positions or unmatched applicants.

During the 2023 Match process, this news organization has been following a handful of students, checking in with them periodically for updates on their progress. Most of them matched successfully, but at least one international medical graduate (IMG) did not. What the others have in common is that their hearts were set on a chosen specialty. Like Ms. Nagle, another student banked on landing his chosen specialty without a backup plan, whereas another said that she’d continue through the SOAP if she didn’t match successfully.

Overall, Match Day resulted in a record number of residency positions offered, most notably in primary care, which “hit an all-time high,” according to NRMP President and CEO Donna L. Lamb, DHSc, MBA, BSN. The number of positions has “consistently increased over the past 5 years, and most importantly the fill rate for primary care has remained steady,” Dr.. Lamb noted in the NRMP release of Match Day results. The release coincided with students learning through emails at noon Eastern Time to which residency or supplemental programs they were matched.

Though more applicants registered for the Match in 2023 than in 2022 – driven primarily by non-U.S. IMGs – the NRMP stated that it was surprised by the decrease in U.S. MD senior applicants.

U.S. MD seniors had a nearly 94% Match rate, a small increase over 2022. U.S. citizen IMGs saw a nearly 68% Match rate, which NRMP reported as an “all-time high” and about six percentage points over in 2022, whereas non-U.S. IMGs had a nearly 60% Match rate, a 1.3 percentage point increase over 2022.

Among the specialties that filled all available positions in 2023 were orthopedic surgery, plastic surgery (integrated), and radiology – diagnostic and thoracic surgery.
 

Not everyone matches

On March 13, the American College of Emergency Physicians issued a joint statement with other emergency medicine (EM) organizations about a high rate of unfilled EM positions expected in 2023.

NRMP acknowledged March 17 that 554 positions remained unfilled, an increase of 335 more unfilled positions than 2022. NRMP attributed the increase in unfilled positions in part to a decrease in the number of U.S. MD and U.S. DO seniors who submitted ranks for the specialty, which “could reflect changing applicant interests or projections about workforce opportunities post residency.”

Applicants who didn’t match usually try to obtain an unfilled position through SOAP. In 2023, 2,685 positions were unfilled after the matching algorithm was processed, an increase of nearly 19% over 2022. The vast majority of those positions were placed in SOAP, an increase of 17.5% over 2022.

Asim Ansari was one of the unlucky ones. Mr. Ansari was trying to match for the fifth time. He was unsuccessful in doing so again in 2023 in the Match and SOAP. Still, he was offered and accepted a child and adolescent psychiatry fellowship at Kansas University Medical Center in Kansas City. Psychiatry was his chosen specialty, so he was “feeling good. It’s a nice place to go to do the next 2 years.”

Mr. Ansari, who started the #MatchMadness support group for unmatched doctors on Twitter Spaces, was quick to cheer on his fellow matching peers on March 13 while revealing his own fate: “Congratulations to everyone who matched!!! Y’all are amazing. So proud of each one of you!!! I didn’t.”

Soon after the results, #MatchMadness held a #Soap2023 support session, and Mr. Ansari sought advice for those willing to review SOAP applications. Elsewhere on Twitter Match Day threads, a few doctors offered their support to those who planned to SOAP, students announced their matches, and others either congratulated or encouraged those still trying to match.
 

Couples match

Not everyone who matched considered the alternative. Before March 13, William Boyer said that he hadn’t given much thought to what would happen if he didn’t match because he was “optimistically confident” he would match into his chosen EM specialty. But he did and got his top choice of programs: Yale New Haven (Conn.) Hospital.

“I feel great,” he said in an interview. “I was definitely nervous opening the envelope” that revealed his residency program, “but there was a rush of relief” when he saw he landed Yale.

Earlier in the match cycle, he said in an interview that he “interviewed at a few ‘reach’ programs, so I hope I don’t match lower than expected on my rank list.”

Mr. Boyer considers himself “a mature applicant,” entering the University of South Carolina, Columbia, after 4 years as an insurance broker.

“I am celebrating today by playing pickleball with a few close medical friends who also matched this morning,” Mr. Boyer said on March 13. “I definitely had periods of nervousness leading up to this morning though that quickly turned into joy and relief” after learning he matched.

Mr. Boyer believes that his professional experience in the insurance industry and health care lobbying efforts with the National Association of Health Underwriters set him apart from other applicants.

“I changed careers to pursue this aspiration, which demonstrates my full dedication to the medical profession.”

He applied to 48 programs and was offered interviews to nearly half. Mr. Boyer visited the majority of those virtually. He said he targeted programs close to where his and his partner’s families are located: Massachusetts, North Carolina, and Texas. “My partner, who I met in medical school, matched into ortho as well so the whole household is very happy,” Mr. Boyer said.

She matched into her top choice as well on March 17, though a distance away at UT Health in San Antonio, he said. “We are both ecstatic. We both got our no. 1 choice. That was the plan going into it. We will make it work. I have 4 weeks of vacation.”

In his program choices, Mr. Boyer prioritized access to nature, minimal leadership turnover, a mix of clinical training sites, and adequate elective rotations and fellowship opportunities, such as in wilderness medicine and health policy.

NRMP reported that there were 1,239 couples participating in the Match; 1,095 had both partners match, and 114 had one partner match to residency training programs for a match rate of 93%.

Like Mr. Boyer, Hannah Hedriana matched into EM, one of the more popular despite the reported unfilled positions. In the past few years, it has consistently been one of the fastest-growing specialties, according to the NRMP.

Still Ms. Hedriana had a fall-back plan. “If I don’t match, then I do plan on going through SOAP. With the number of EM spots that were unfilled in 2022, there’s a chance I could still be an EM physician, but if not, then that’s okay with me.”

Her reaction on March 13, after learning she matched? “Super excited, celebrating with my friends right now.” On Match Day, she said she was “ecstatic” to be matched into Lakeland (Fla.) Regional Health. “This was my first choice so now I can stay close to family and friends,” she said in an interview soon after the results were released.

A first-generation, Filipino American student from the University of South Florida, Tampa, Ms. Hedriana comes from a family of health care professionals. Her father is a respiratory therapist turned physical therapist; her mother a registered nurse. Her sister is a patient care technician applying to nursing school.

Ms. Hedriana applied to 70 programs and interviewed mostly online with 24. Her goal was to stay on the East Coast.

“My partner is a licensed dentist in the state of Florida, and so for his career it would be more practical to stay in state, rather than get relicensed in another state, which could take months,” she said earlier in the matching cycle. “However, when we discussed choosing a residency program, he ultimately left it up to me and wanted me to pick where I thought I’d flourish best,” Ms. Hedriana said, adding that her family lives in Florida, too.

She said she sought a residency program that values family and teamwork.

“A program gets more points in my book if they have sites at nonprofit hospitals or has residents that regularly volunteer throughout their communities or participate in DEI [diversity, equity, and inclusion] initiatives.”

Ms. Hedriana noted that some specialties exclusively offered virtual interviews in 2023, whereas other specialties favored in-person interviews. “This year, many of my classmates were able to do multiple away rotations, which they saw as a positive regarding their chances of matching.” During COVID, in-person visits were limited.

“However, I’ve noticed that many of my classmates are not fond of the signaling aspect that was present for this year’s cycle,” she said. Signaling is a relatively new process that allows applicants to indicate interest in a limited number of residency programs. Not all residencies participate, but it’s growing in popularity among specialties, according to the American Medical Association.
 

‘Extremely competitive’

Ms. Nagle, a second lieutenant in the U.S. Air Force, applied to 12 programs and interviewed with half of them online. She said that she wasn’t targeting any specific type of program through the match.

“I believe you can get phenomenal training anywhere where you mesh with the residents and leadership. My ultimate priority is to (1) be near good people, (2) be near good food (Indian and Thai are a must), and (3) be near an international airport so I can flee the country during breaks.”

Meanwhile, she said that she found the application process, in which students have to articulate their entire medical school experience, extremely competitive. “I think this process is so easy to get wound up in and the anxiety can be palpable,” Ms. Nagle said. “People around you match your energy. So if you are a ball of anxiety then so are your attendings and residents – and that doesn’t bode well for passing the ‘do I want to be on call with them’ test.”

Looking back at medical school, Ms. Nagle recalled having a baby named after her during her first anesthesia rotation and being featured on The Kelly Clarkson Show. Ms. Nagle said that she had walked into the delivery room where new parents had been debating names of babies beginning with the letter B. “And when I introduced myself, they looked at each other and said, ‘Yep, that’s the one.’”

Mr. Boyer recounted how the majority of his medical school experience involved online education. “Roughly two-thirds of my first year was in-person prior to the pandemic. However, from spring break first year to in-person clinical rotations at the beginning of third year, we were all virtual. While I missed interacting with my classmates, I benefited from the virtual learning environment as I learn more efficiently from reading and visual aids than auditory lectures.”

Ms. Hedriana cited the friends and memories she made while learning to be a doctor. “Medical school was hard, but I wouldn’t have changed a thing.”

A version of this article first appeared on Medscape.com.

Baily Nagle, vice president of her graduating class at Harvard Medical School, Boston, celebrated “the luck of the Irish” on St. Patrick’s Day that allowed her to match into her chosen specialty and top choice of residency programs: anesthesia at Brigham and Women’s Hospital.

“I am feeling very excited and relieved – I matched,” she said in an interview upon hearing her good fortune on Match Monday, March 13. She had a similar reaction on Match Day, March 17. “After a lot of long nights and hard work, happy to have it pay off.”

Ms. Nagle was so determined to match into her specialty that she didn’t have any other specialties in mind as a backup.

The annual process of matching medical school graduates with compatible residency programs is an emotional roller coaster for all applicants, their personal March Madness, so to speak. But Ms. Nagle was one of the more fortunate applicants. She didn’t have to confront the heartbreak other applicants felt when the National Resident Matching Program (NRMP) announced results of the main residency match and the Supplemental Offer and Acceptance Program (SOAP), which offers alternate programs for unfilled positions or unmatched applicants.

During the 2023 Match process, this news organization has been following a handful of students, checking in with them periodically for updates on their progress. Most of them matched successfully, but at least one international medical graduate (IMG) did not. What the others have in common is that their hearts were set on a chosen specialty. Like Ms. Nagle, another student banked on landing his chosen specialty without a backup plan, whereas another said that she’d continue through the SOAP if she didn’t match successfully.

Overall, Match Day resulted in a record number of residency positions offered, most notably in primary care, which “hit an all-time high,” according to NRMP President and CEO Donna L. Lamb, DHSc, MBA, BSN. The number of positions has “consistently increased over the past 5 years, and most importantly the fill rate for primary care has remained steady,” Dr.. Lamb noted in the NRMP release of Match Day results. The release coincided with students learning through emails at noon Eastern Time to which residency or supplemental programs they were matched.

Though more applicants registered for the Match in 2023 than in 2022 – driven primarily by non-U.S. IMGs – the NRMP stated that it was surprised by the decrease in U.S. MD senior applicants.

U.S. MD seniors had a nearly 94% Match rate, a small increase over 2022. U.S. citizen IMGs saw a nearly 68% Match rate, which NRMP reported as an “all-time high” and about six percentage points over in 2022, whereas non-U.S. IMGs had a nearly 60% Match rate, a 1.3 percentage point increase over 2022.

Among the specialties that filled all available positions in 2023 were orthopedic surgery, plastic surgery (integrated), and radiology – diagnostic and thoracic surgery.
 

Not everyone matches

On March 13, the American College of Emergency Physicians issued a joint statement with other emergency medicine (EM) organizations about a high rate of unfilled EM positions expected in 2023.

NRMP acknowledged March 17 that 554 positions remained unfilled, an increase of 335 more unfilled positions than 2022. NRMP attributed the increase in unfilled positions in part to a decrease in the number of U.S. MD and U.S. DO seniors who submitted ranks for the specialty, which “could reflect changing applicant interests or projections about workforce opportunities post residency.”

Applicants who didn’t match usually try to obtain an unfilled position through SOAP. In 2023, 2,685 positions were unfilled after the matching algorithm was processed, an increase of nearly 19% over 2022. The vast majority of those positions were placed in SOAP, an increase of 17.5% over 2022.

Asim Ansari was one of the unlucky ones. Mr. Ansari was trying to match for the fifth time. He was unsuccessful in doing so again in 2023 in the Match and SOAP. Still, he was offered and accepted a child and adolescent psychiatry fellowship at Kansas University Medical Center in Kansas City. Psychiatry was his chosen specialty, so he was “feeling good. It’s a nice place to go to do the next 2 years.”

Mr. Ansari, who started the #MatchMadness support group for unmatched doctors on Twitter Spaces, was quick to cheer on his fellow matching peers on March 13 while revealing his own fate: “Congratulations to everyone who matched!!! Y’all are amazing. So proud of each one of you!!! I didn’t.”

Soon after the results, #MatchMadness held a #Soap2023 support session, and Mr. Ansari sought advice for those willing to review SOAP applications. Elsewhere on Twitter Match Day threads, a few doctors offered their support to those who planned to SOAP, students announced their matches, and others either congratulated or encouraged those still trying to match.
 

Couples match

Not everyone who matched considered the alternative. Before March 13, William Boyer said that he hadn’t given much thought to what would happen if he didn’t match because he was “optimistically confident” he would match into his chosen EM specialty. But he did and got his top choice of programs: Yale New Haven (Conn.) Hospital.

“I feel great,” he said in an interview. “I was definitely nervous opening the envelope” that revealed his residency program, “but there was a rush of relief” when he saw he landed Yale.

Earlier in the match cycle, he said in an interview that he “interviewed at a few ‘reach’ programs, so I hope I don’t match lower than expected on my rank list.”

Mr. Boyer considers himself “a mature applicant,” entering the University of South Carolina, Columbia, after 4 years as an insurance broker.

“I am celebrating today by playing pickleball with a few close medical friends who also matched this morning,” Mr. Boyer said on March 13. “I definitely had periods of nervousness leading up to this morning though that quickly turned into joy and relief” after learning he matched.

Mr. Boyer believes that his professional experience in the insurance industry and health care lobbying efforts with the National Association of Health Underwriters set him apart from other applicants.

“I changed careers to pursue this aspiration, which demonstrates my full dedication to the medical profession.”

He applied to 48 programs and was offered interviews to nearly half. Mr. Boyer visited the majority of those virtually. He said he targeted programs close to where his and his partner’s families are located: Massachusetts, North Carolina, and Texas. “My partner, who I met in medical school, matched into ortho as well so the whole household is very happy,” Mr. Boyer said.

She matched into her top choice as well on March 17, though a distance away at UT Health in San Antonio, he said. “We are both ecstatic. We both got our no. 1 choice. That was the plan going into it. We will make it work. I have 4 weeks of vacation.”

In his program choices, Mr. Boyer prioritized access to nature, minimal leadership turnover, a mix of clinical training sites, and adequate elective rotations and fellowship opportunities, such as in wilderness medicine and health policy.

NRMP reported that there were 1,239 couples participating in the Match; 1,095 had both partners match, and 114 had one partner match to residency training programs for a match rate of 93%.

Like Mr. Boyer, Hannah Hedriana matched into EM, one of the more popular despite the reported unfilled positions. In the past few years, it has consistently been one of the fastest-growing specialties, according to the NRMP.

Still Ms. Hedriana had a fall-back plan. “If I don’t match, then I do plan on going through SOAP. With the number of EM spots that were unfilled in 2022, there’s a chance I could still be an EM physician, but if not, then that’s okay with me.”

Her reaction on March 13, after learning she matched? “Super excited, celebrating with my friends right now.” On Match Day, she said she was “ecstatic” to be matched into Lakeland (Fla.) Regional Health. “This was my first choice so now I can stay close to family and friends,” she said in an interview soon after the results were released.

A first-generation, Filipino American student from the University of South Florida, Tampa, Ms. Hedriana comes from a family of health care professionals. Her father is a respiratory therapist turned physical therapist; her mother a registered nurse. Her sister is a patient care technician applying to nursing school.

Ms. Hedriana applied to 70 programs and interviewed mostly online with 24. Her goal was to stay on the East Coast.

“My partner is a licensed dentist in the state of Florida, and so for his career it would be more practical to stay in state, rather than get relicensed in another state, which could take months,” she said earlier in the matching cycle. “However, when we discussed choosing a residency program, he ultimately left it up to me and wanted me to pick where I thought I’d flourish best,” Ms. Hedriana said, adding that her family lives in Florida, too.

She said she sought a residency program that values family and teamwork.

“A program gets more points in my book if they have sites at nonprofit hospitals or has residents that regularly volunteer throughout their communities or participate in DEI [diversity, equity, and inclusion] initiatives.”

Ms. Hedriana noted that some specialties exclusively offered virtual interviews in 2023, whereas other specialties favored in-person interviews. “This year, many of my classmates were able to do multiple away rotations, which they saw as a positive regarding their chances of matching.” During COVID, in-person visits were limited.

“However, I’ve noticed that many of my classmates are not fond of the signaling aspect that was present for this year’s cycle,” she said. Signaling is a relatively new process that allows applicants to indicate interest in a limited number of residency programs. Not all residencies participate, but it’s growing in popularity among specialties, according to the American Medical Association.
 

‘Extremely competitive’

Ms. Nagle, a second lieutenant in the U.S. Air Force, applied to 12 programs and interviewed with half of them online. She said that she wasn’t targeting any specific type of program through the match.

“I believe you can get phenomenal training anywhere where you mesh with the residents and leadership. My ultimate priority is to (1) be near good people, (2) be near good food (Indian and Thai are a must), and (3) be near an international airport so I can flee the country during breaks.”

Meanwhile, she said that she found the application process, in which students have to articulate their entire medical school experience, extremely competitive. “I think this process is so easy to get wound up in and the anxiety can be palpable,” Ms. Nagle said. “People around you match your energy. So if you are a ball of anxiety then so are your attendings and residents – and that doesn’t bode well for passing the ‘do I want to be on call with them’ test.”

Looking back at medical school, Ms. Nagle recalled having a baby named after her during her first anesthesia rotation and being featured on The Kelly Clarkson Show. Ms. Nagle said that she had walked into the delivery room where new parents had been debating names of babies beginning with the letter B. “And when I introduced myself, they looked at each other and said, ‘Yep, that’s the one.’”

Mr. Boyer recounted how the majority of his medical school experience involved online education. “Roughly two-thirds of my first year was in-person prior to the pandemic. However, from spring break first year to in-person clinical rotations at the beginning of third year, we were all virtual. While I missed interacting with my classmates, I benefited from the virtual learning environment as I learn more efficiently from reading and visual aids than auditory lectures.”

Ms. Hedriana cited the friends and memories she made while learning to be a doctor. “Medical school was hard, but I wouldn’t have changed a thing.”

A version of this article first appeared on Medscape.com.

New data released by the U.S. Department of Defense show that the incidence of many types of cancer is higher among military pilots and aviation support personnel in comparison with the general population.

“Military aircrew and ground crew were overall more likely to be diagnosed with cancer, but less likely to die from cancer compared to the U.S. population,” the report concludes.

The study involved 156,050 aircrew and 737,891 ground crew. Participants were followed between 1992 and 2017. Both groups were predominantly male and non-Hispanic.

Data on cancer incidence and mortality for these two groups were compared with data from groups of similar age in the general population through use of the Surveillance, Epidemiology, and End Results (SEER) Database of the National Cancer Institute.

For aircrew, the study found an 87% higher rate of melanoma, a 39% higher rate of thyroid cancer, a 16% higher rate of prostate cancer, and a 24% higher rate of cancer for all sites combined.

A higher rate of melanoma and prostate cancer among aircrew has been reported previously, but the increased rate of thyroid cancer is a new finding, the authors note.

The uptick in melanoma has also been reported in studies of civilian pilots and cabin crew. It has been attributed to exposure to hazardous ultraviolet and cosmic radiation.

For ground crew members, the analysis found a 19% higher rate of cancers of the brain and nervous system, a 15% higher rate of thyroid cancer, a 9% higher rate of melanoma and of kidney and renal pelvis cancers, and a 3% higher rate of cancer for all sites combined.

There is little to compare these findings with: This is the first time that cancer risk has been evaluated in such a large population of military ground crew.
 

Lower rates of cancer mortality

In contrast to the increase in cancer incidence, the report found a decrease in cancer mortality.

When compared with a demographically similar U.S. population, the mortality rate among aircrew was 56% lower for all cancer sites; for ground crew, the mortality rate was 35% lower.

However, the report authors emphasize that “it is important to note that the military study population was relatively young.”

The median age at the end of follow-up for the cancer incidence analysis was 41 years for aircrew and 26 years for ground crew. The median age at the end of follow-up for the cancer mortality analysis was 48 years for aircrew and 41 years for ground crew.

“Results may have differed if additional older former Service members had been included in the study, since cancer risk and mortality rates increase with age,” the authors comment.

Other studies have found an increase in deaths from melanoma as well as an increase in the incidence of melanoma. A meta-analysis published in 2019 in the British Journal of Dermatology found that airline pilots and cabin crew have about twice the risk of melanoma and other skin cancers than the general population. Pilots are also more likely to die from melanoma.
 

Further study underway

The findings on military air and ground crew come from phase 1 of a study that was required by Congress in the 2021 defense bill. Because the investigators found an increase in the incidence of cancer, phase 2 of the study is now necessary.

The report authors explain that phase 2 will consist of identifying the carcinogenic toxicants or hazardous materials associated with military flight operations; identifying operating environments that could be associated with increased amounts of ionizing and nonionizing radiation; identifying specific duties, dates of service, and types of aircraft flown that could have increased the risk for cancer; identifying duty locations associated with a higher incidence of cancers; identifying potential exposures through military service that are not related to aviation; and determining the appropriate age to begin screening military aircrew and ground crew for cancers.

A version of this article first appeared on Medscape.com.

New data released by the U.S. Department of Defense show that the incidence of many types of cancer is higher among military pilots and aviation support personnel in comparison with the general population.

“Military aircrew and ground crew were overall more likely to be diagnosed with cancer, but less likely to die from cancer compared to the U.S. population,” the report concludes.

The study involved 156,050 aircrew and 737,891 ground crew. Participants were followed between 1992 and 2017. Both groups were predominantly male and non-Hispanic.

Data on cancer incidence and mortality for these two groups were compared with data from groups of similar age in the general population through use of the Surveillance, Epidemiology, and End Results (SEER) Database of the National Cancer Institute.

For aircrew, the study found an 87% higher rate of melanoma, a 39% higher rate of thyroid cancer, a 16% higher rate of prostate cancer, and a 24% higher rate of cancer for all sites combined.

A higher rate of melanoma and prostate cancer among aircrew has been reported previously, but the increased rate of thyroid cancer is a new finding, the authors note.

The uptick in melanoma has also been reported in studies of civilian pilots and cabin crew. It has been attributed to exposure to hazardous ultraviolet and cosmic radiation.

For ground crew members, the analysis found a 19% higher rate of cancers of the brain and nervous system, a 15% higher rate of thyroid cancer, a 9% higher rate of melanoma and of kidney and renal pelvis cancers, and a 3% higher rate of cancer for all sites combined.

There is little to compare these findings with: This is the first time that cancer risk has been evaluated in such a large population of military ground crew.
 

Lower rates of cancer mortality

In contrast to the increase in cancer incidence, the report found a decrease in cancer mortality.

When compared with a demographically similar U.S. population, the mortality rate among aircrew was 56% lower for all cancer sites; for ground crew, the mortality rate was 35% lower.

However, the report authors emphasize that “it is important to note that the military study population was relatively young.”

The median age at the end of follow-up for the cancer incidence analysis was 41 years for aircrew and 26 years for ground crew. The median age at the end of follow-up for the cancer mortality analysis was 48 years for aircrew and 41 years for ground crew.

“Results may have differed if additional older former Service members had been included in the study, since cancer risk and mortality rates increase with age,” the authors comment.

Other studies have found an increase in deaths from melanoma as well as an increase in the incidence of melanoma. A meta-analysis published in 2019 in the British Journal of Dermatology found that airline pilots and cabin crew have about twice the risk of melanoma and other skin cancers than the general population. Pilots are also more likely to die from melanoma.
 

Further study underway

The findings on military air and ground crew come from phase 1 of a study that was required by Congress in the 2021 defense bill. Because the investigators found an increase in the incidence of cancer, phase 2 of the study is now necessary.

The report authors explain that phase 2 will consist of identifying the carcinogenic toxicants or hazardous materials associated with military flight operations; identifying operating environments that could be associated with increased amounts of ionizing and nonionizing radiation; identifying specific duties, dates of service, and types of aircraft flown that could have increased the risk for cancer; identifying duty locations associated with a higher incidence of cancers; identifying potential exposures through military service that are not related to aviation; and determining the appropriate age to begin screening military aircrew and ground crew for cancers.

A version of this article first appeared on Medscape.com.

New data released by the U.S. Department of Defense show that the incidence of many types of cancer is higher among military pilots and aviation support personnel in comparison with the general population.

“Military aircrew and ground crew were overall more likely to be diagnosed with cancer, but less likely to die from cancer compared to the U.S. population,” the report concludes.

The study involved 156,050 aircrew and 737,891 ground crew. Participants were followed between 1992 and 2017. Both groups were predominantly male and non-Hispanic.

Data on cancer incidence and mortality for these two groups were compared with data from groups of similar age in the general population through use of the Surveillance, Epidemiology, and End Results (SEER) Database of the National Cancer Institute.

For aircrew, the study found an 87% higher rate of melanoma, a 39% higher rate of thyroid cancer, a 16% higher rate of prostate cancer, and a 24% higher rate of cancer for all sites combined.

A higher rate of melanoma and prostate cancer among aircrew has been reported previously, but the increased rate of thyroid cancer is a new finding, the authors note.

The uptick in melanoma has also been reported in studies of civilian pilots and cabin crew. It has been attributed to exposure to hazardous ultraviolet and cosmic radiation.

For ground crew members, the analysis found a 19% higher rate of cancers of the brain and nervous system, a 15% higher rate of thyroid cancer, a 9% higher rate of melanoma and of kidney and renal pelvis cancers, and a 3% higher rate of cancer for all sites combined.

There is little to compare these findings with: This is the first time that cancer risk has been evaluated in such a large population of military ground crew.
 

Lower rates of cancer mortality

In contrast to the increase in cancer incidence, the report found a decrease in cancer mortality.

When compared with a demographically similar U.S. population, the mortality rate among aircrew was 56% lower for all cancer sites; for ground crew, the mortality rate was 35% lower.

However, the report authors emphasize that “it is important to note that the military study population was relatively young.”

The median age at the end of follow-up for the cancer incidence analysis was 41 years for aircrew and 26 years for ground crew. The median age at the end of follow-up for the cancer mortality analysis was 48 years for aircrew and 41 years for ground crew.

“Results may have differed if additional older former Service members had been included in the study, since cancer risk and mortality rates increase with age,” the authors comment.

Other studies have found an increase in deaths from melanoma as well as an increase in the incidence of melanoma. A meta-analysis published in 2019 in the British Journal of Dermatology found that airline pilots and cabin crew have about twice the risk of melanoma and other skin cancers than the general population. Pilots are also more likely to die from melanoma.
 

Further study underway

The findings on military air and ground crew come from phase 1 of a study that was required by Congress in the 2021 defense bill. Because the investigators found an increase in the incidence of cancer, phase 2 of the study is now necessary.

The report authors explain that phase 2 will consist of identifying the carcinogenic toxicants or hazardous materials associated with military flight operations; identifying operating environments that could be associated with increased amounts of ionizing and nonionizing radiation; identifying specific duties, dates of service, and types of aircraft flown that could have increased the risk for cancer; identifying duty locations associated with a higher incidence of cancers; identifying potential exposures through military service that are not related to aviation; and determining the appropriate age to begin screening military aircrew and ground crew for cancers.

A version of this article first appeared on Medscape.com.

The only true wisdom is in knowing you know nothing. – Socrates

At what age is one supposed to be wise? I feel like I’m falling behind. I’ve crossed the middle of life and can check the prerequisite experiences: Joy, tragedy, love, adventure, love again. I lived a jetsetter life with an overnight bag always packed. I’ve sported the “Dad AF” tee with a fully loaded dad-pack. I’ve seen the 50 states and had my picture wrapped on a city bus (super-weird when you pull up next to one). Yet, when a moment arrives to pop in pithy advice for a resident or drop a few reassuring lines for a grieving friend, I’m often unable to find the words. If life were a video game, I’ve not earned the wisdom level yet.

Who are the wise men and women in your life? It’s difficult to list them. This is because it’s a complex attribute and hard to explain. It’s also because the wise who walk among us are rare. Wise is more than being brilliant at bullous diseases or knowing how to sleep train a baby. Nor is wise the buddy who purchased $1,000 of Bitcoin in 2010 (although stay close with him, he probably owns a jet). Neither content experts nor lucky friends rise to the appellation. To be wise you have to not only make good decisions, but also offer good advice. You need both knowledge and insight. Both experience and empathy.

Public domain/Wikimedia Commons

The ancients considered wisdom to be one of the vital virtues. It was personified in high-profile gods like Apollo and Athena. It’s rare and important enough to be seen as spiritual. It features heavily in the Bible, the Bhagavad Gita, the Meditations of Marcus Aurelius. In some cultures the wise are called elders or sages. In all cultures they are helpful, respected, sought after, appreciated. We need more wise people in this game of life. I want to be one. But there’s no Coursera for it.

To become wise you have to pass through many levels, put in a lot of reps, suffer through many sleepless nights. Like the third molar, also known as the wisdom tooth, it takes years. You also have to emerge stronger and smarter through those experiences. FDR would not have become one of the wisest presidents in history had it not been for his trials, and victories, over polio. Osler missed Cushing syndrome multiple times before he got it right. It seems you have to go to the mountain, like Batman, and fight a few battles to realize your full wisdom potential.

You must also reflect on your experiences and hone your insight. The management sage Peter Drucker would write what he expected to happen after a decision. Then he’d return to it to hone his intuition and judgment.

Lastly, you have to use your powers for good. Using insight to win your NCAA bracket pool isn’t wisdom. Helping a friend whose marriage is falling apart or colleague whose patient is suing them or a resident whose excision hit an arteriole surely is.

I’ve got a ways to go before anyone puts me on their wise friend list. I’m working on it though. Perhaps you will too – we are desperately short-staffed in this area. For now, I can start with writing better condolences.



“Who maintains that it is not a heavy blow? But it is part of being human.” – Seneca

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

The only true wisdom is in knowing you know nothing. – Socrates

At what age is one supposed to be wise? I feel like I’m falling behind. I’ve crossed the middle of life and can check the prerequisite experiences: Joy, tragedy, love, adventure, love again. I lived a jetsetter life with an overnight bag always packed. I’ve sported the “Dad AF” tee with a fully loaded dad-pack. I’ve seen the 50 states and had my picture wrapped on a city bus (super-weird when you pull up next to one). Yet, when a moment arrives to pop in pithy advice for a resident or drop a few reassuring lines for a grieving friend, I’m often unable to find the words. If life were a video game, I’ve not earned the wisdom level yet.

Who are the wise men and women in your life? It’s difficult to list them. This is because it’s a complex attribute and hard to explain. It’s also because the wise who walk among us are rare. Wise is more than being brilliant at bullous diseases or knowing how to sleep train a baby. Nor is wise the buddy who purchased $1,000 of Bitcoin in 2010 (although stay close with him, he probably owns a jet). Neither content experts nor lucky friends rise to the appellation. To be wise you have to not only make good decisions, but also offer good advice. You need both knowledge and insight. Both experience and empathy.

Public domain/Wikimedia Commons

The ancients considered wisdom to be one of the vital virtues. It was personified in high-profile gods like Apollo and Athena. It’s rare and important enough to be seen as spiritual. It features heavily in the Bible, the Bhagavad Gita, the Meditations of Marcus Aurelius. In some cultures the wise are called elders or sages. In all cultures they are helpful, respected, sought after, appreciated. We need more wise people in this game of life. I want to be one. But there’s no Coursera for it.

To become wise you have to pass through many levels, put in a lot of reps, suffer through many sleepless nights. Like the third molar, also known as the wisdom tooth, it takes years. You also have to emerge stronger and smarter through those experiences. FDR would not have become one of the wisest presidents in history had it not been for his trials, and victories, over polio. Osler missed Cushing syndrome multiple times before he got it right. It seems you have to go to the mountain, like Batman, and fight a few battles to realize your full wisdom potential.

You must also reflect on your experiences and hone your insight. The management sage Peter Drucker would write what he expected to happen after a decision. Then he’d return to it to hone his intuition and judgment.

Lastly, you have to use your powers for good. Using insight to win your NCAA bracket pool isn’t wisdom. Helping a friend whose marriage is falling apart or colleague whose patient is suing them or a resident whose excision hit an arteriole surely is.

I’ve got a ways to go before anyone puts me on their wise friend list. I’m working on it though. Perhaps you will too – we are desperately short-staffed in this area. For now, I can start with writing better condolences.



“Who maintains that it is not a heavy blow? But it is part of being human.” – Seneca

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

The only true wisdom is in knowing you know nothing. – Socrates

At what age is one supposed to be wise? I feel like I’m falling behind. I’ve crossed the middle of life and can check the prerequisite experiences: Joy, tragedy, love, adventure, love again. I lived a jetsetter life with an overnight bag always packed. I’ve sported the “Dad AF” tee with a fully loaded dad-pack. I’ve seen the 50 states and had my picture wrapped on a city bus (super-weird when you pull up next to one). Yet, when a moment arrives to pop in pithy advice for a resident or drop a few reassuring lines for a grieving friend, I’m often unable to find the words. If life were a video game, I’ve not earned the wisdom level yet.

Who are the wise men and women in your life? It’s difficult to list them. This is because it’s a complex attribute and hard to explain. It’s also because the wise who walk among us are rare. Wise is more than being brilliant at bullous diseases or knowing how to sleep train a baby. Nor is wise the buddy who purchased $1,000 of Bitcoin in 2010 (although stay close with him, he probably owns a jet). Neither content experts nor lucky friends rise to the appellation. To be wise you have to not only make good decisions, but also offer good advice. You need both knowledge and insight. Both experience and empathy.

Public domain/Wikimedia Commons

The ancients considered wisdom to be one of the vital virtues. It was personified in high-profile gods like Apollo and Athena. It’s rare and important enough to be seen as spiritual. It features heavily in the Bible, the Bhagavad Gita, the Meditations of Marcus Aurelius. In some cultures the wise are called elders or sages. In all cultures they are helpful, respected, sought after, appreciated. We need more wise people in this game of life. I want to be one. But there’s no Coursera for it.

To become wise you have to pass through many levels, put in a lot of reps, suffer through many sleepless nights. Like the third molar, also known as the wisdom tooth, it takes years. You also have to emerge stronger and smarter through those experiences. FDR would not have become one of the wisest presidents in history had it not been for his trials, and victories, over polio. Osler missed Cushing syndrome multiple times before he got it right. It seems you have to go to the mountain, like Batman, and fight a few battles to realize your full wisdom potential.

You must also reflect on your experiences and hone your insight. The management sage Peter Drucker would write what he expected to happen after a decision. Then he’d return to it to hone his intuition and judgment.

Lastly, you have to use your powers for good. Using insight to win your NCAA bracket pool isn’t wisdom. Helping a friend whose marriage is falling apart or colleague whose patient is suing them or a resident whose excision hit an arteriole surely is.

I’ve got a ways to go before anyone puts me on their wise friend list. I’m working on it though. Perhaps you will too – we are desperately short-staffed in this area. For now, I can start with writing better condolences.



“Who maintains that it is not a heavy blow? But it is part of being human.” – Seneca

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

The Environmental Protection Agency is proposing a new rule that would greatly limit the concentration of endocrine-disrupting “forever” chemicals in drinking water. 

The EPA on Tuesday announced the proposed National Primary Drinking Water Regulation (NPDWR) for six polyfluoroalkyl substances, more commonly known as PFAS, which are human-made chemicals used as oil and water repellents and coatings for common products including cookware, carpets, and textiles. Such substances are also widely used in cosmetics and food packaging.

curtoicurto/Getty Images

The Endocrine Society, which represents more than 18,000 doctors who treat hormone disorders, says it fully supports the new EPA proposal. It explains that these substances, also known as endocrine-disrupting chemicals, “do not break down when they are released into the environment, and they continue to accumulate over time. They pose health dangers at incredibly low levels and have been linked to endocrine disorders such as cancer, thyroid disruption, and reproductive difficulties.”

“This is the first time the government has regulated a new chemical in drinking water in more than 30 years,” the society notes, adding, this “will require major water treatment upgrades at utilities across the country.”

Robert F. Powelson, president and CEO of the National Association of Water Companies, says addressing the PFAS in the nation’s water supply will cost “billions of dollars.”

“It’s a burden that under the current structure will disproportionately fall on water and wastewater customers in small communities and low-income families,” Mr. Powelson says in a statement. He says the onus should instead fall on “the polluters” – those who manufacture and use PFAS chemicals, who “should be held directly responsible for the clean-up costs.” 

Although the EPA is proposing a health-based maximum contaminant level goal of zero for these chemicals in drinking water, it acknowledges that this is unenforceable and so has set what it considers an enforceable level, or maximum contaminant level (MCL), of 4 parts per trillion for two of the PFAS, perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS). 

A different standard has been proposed for the remaining four chemicals: perfluorononanoic acid (PFNA) and hexafluoropropylene oxide dimer acid (HFPO-DA) – known together as GenX chemicals – perfluorohexane sulfonic acid (PFHxS), and perfluorobutane sulfonic acid (PFBS).

Officials from the EPA told The Washington Post that these proposed limits would be as strong or stronger than limits from about a dozen states that have set their own drinking water standards in recent years. 

“The experts here felt this was the level of stringency required to protect public health, and that the law would allow for us,” EPA Administrator Michael Regan told the newspaper. “This is a transformative action that we’re taking.”

The EPA is requesting public comment on the proposed regulation and will hold a public hearing on May 4, which members of the public can register to attend and comment on the rule proposal. The last day to register is April 28. 

The EPA wants to finalize regulation by the end of 2023, although delays are common on new rules. 

If it is fully implemented, “the rule will prevent thousands of deaths and reduce tens of thousands of serious PFAS-attributable illnesses,” the EPA statement says.

A version of this article first appeared on Medscape.com.

The Environmental Protection Agency is proposing a new rule that would greatly limit the concentration of endocrine-disrupting “forever” chemicals in drinking water. 

The EPA on Tuesday announced the proposed National Primary Drinking Water Regulation (NPDWR) for six polyfluoroalkyl substances, more commonly known as PFAS, which are human-made chemicals used as oil and water repellents and coatings for common products including cookware, carpets, and textiles. Such substances are also widely used in cosmetics and food packaging.

curtoicurto/Getty Images

The Endocrine Society, which represents more than 18,000 doctors who treat hormone disorders, says it fully supports the new EPA proposal. It explains that these substances, also known as endocrine-disrupting chemicals, “do not break down when they are released into the environment, and they continue to accumulate over time. They pose health dangers at incredibly low levels and have been linked to endocrine disorders such as cancer, thyroid disruption, and reproductive difficulties.”

“This is the first time the government has regulated a new chemical in drinking water in more than 30 years,” the society notes, adding, this “will require major water treatment upgrades at utilities across the country.”

Robert F. Powelson, president and CEO of the National Association of Water Companies, says addressing the PFAS in the nation’s water supply will cost “billions of dollars.”

“It’s a burden that under the current structure will disproportionately fall on water and wastewater customers in small communities and low-income families,” Mr. Powelson says in a statement. He says the onus should instead fall on “the polluters” – those who manufacture and use PFAS chemicals, who “should be held directly responsible for the clean-up costs.” 

Although the EPA is proposing a health-based maximum contaminant level goal of zero for these chemicals in drinking water, it acknowledges that this is unenforceable and so has set what it considers an enforceable level, or maximum contaminant level (MCL), of 4 parts per trillion for two of the PFAS, perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS). 

A different standard has been proposed for the remaining four chemicals: perfluorononanoic acid (PFNA) and hexafluoropropylene oxide dimer acid (HFPO-DA) – known together as GenX chemicals – perfluorohexane sulfonic acid (PFHxS), and perfluorobutane sulfonic acid (PFBS).

Officials from the EPA told The Washington Post that these proposed limits would be as strong or stronger than limits from about a dozen states that have set their own drinking water standards in recent years. 

“The experts here felt this was the level of stringency required to protect public health, and that the law would allow for us,” EPA Administrator Michael Regan told the newspaper. “This is a transformative action that we’re taking.”

The EPA is requesting public comment on the proposed regulation and will hold a public hearing on May 4, which members of the public can register to attend and comment on the rule proposal. The last day to register is April 28. 

The EPA wants to finalize regulation by the end of 2023, although delays are common on new rules. 

If it is fully implemented, “the rule will prevent thousands of deaths and reduce tens of thousands of serious PFAS-attributable illnesses,” the EPA statement says.

A version of this article first appeared on Medscape.com.

The Environmental Protection Agency is proposing a new rule that would greatly limit the concentration of endocrine-disrupting “forever” chemicals in drinking water. 

The EPA on Tuesday announced the proposed National Primary Drinking Water Regulation (NPDWR) for six polyfluoroalkyl substances, more commonly known as PFAS, which are human-made chemicals used as oil and water repellents and coatings for common products including cookware, carpets, and textiles. Such substances are also widely used in cosmetics and food packaging.

curtoicurto/Getty Images

The Endocrine Society, which represents more than 18,000 doctors who treat hormone disorders, says it fully supports the new EPA proposal. It explains that these substances, also known as endocrine-disrupting chemicals, “do not break down when they are released into the environment, and they continue to accumulate over time. They pose health dangers at incredibly low levels and have been linked to endocrine disorders such as cancer, thyroid disruption, and reproductive difficulties.”

“This is the first time the government has regulated a new chemical in drinking water in more than 30 years,” the society notes, adding, this “will require major water treatment upgrades at utilities across the country.”

Robert F. Powelson, president and CEO of the National Association of Water Companies, says addressing the PFAS in the nation’s water supply will cost “billions of dollars.”

“It’s a burden that under the current structure will disproportionately fall on water and wastewater customers in small communities and low-income families,” Mr. Powelson says in a statement. He says the onus should instead fall on “the polluters” – those who manufacture and use PFAS chemicals, who “should be held directly responsible for the clean-up costs.” 

Although the EPA is proposing a health-based maximum contaminant level goal of zero for these chemicals in drinking water, it acknowledges that this is unenforceable and so has set what it considers an enforceable level, or maximum contaminant level (MCL), of 4 parts per trillion for two of the PFAS, perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS). 

A different standard has been proposed for the remaining four chemicals: perfluorononanoic acid (PFNA) and hexafluoropropylene oxide dimer acid (HFPO-DA) – known together as GenX chemicals – perfluorohexane sulfonic acid (PFHxS), and perfluorobutane sulfonic acid (PFBS).

Officials from the EPA told The Washington Post that these proposed limits would be as strong or stronger than limits from about a dozen states that have set their own drinking water standards in recent years. 

“The experts here felt this was the level of stringency required to protect public health, and that the law would allow for us,” EPA Administrator Michael Regan told the newspaper. “This is a transformative action that we’re taking.”

The EPA is requesting public comment on the proposed regulation and will hold a public hearing on May 4, which members of the public can register to attend and comment on the rule proposal. The last day to register is April 28. 

The EPA wants to finalize regulation by the end of 2023, although delays are common on new rules. 

If it is fully implemented, “the rule will prevent thousands of deaths and reduce tens of thousands of serious PFAS-attributable illnesses,” the EPA statement says.

A version of this article first appeared on Medscape.com.

A hybrid closed-loop automated insulin delivery system improved time-in-range for blood glucose, compared with standard care, for children with type 1 diabetes in a 13-week trial.

The hybrid closed-loop system, also called automated insulin delivery or artificial pancreas, was composed of a t:slim X2 insulin pump, a Dexcom G6 continuous glucose monitor (CGM), and Control-IQ technology system algorithm software (Tandem Diabetes Care). The system was approved in the United States in 2018 for adults and children as young as 6 years.

Type 1 diabetes treatment is particularly challenging in children younger than 6 because of their small insulin dosing requirements and unpredictable eating and activity habits, lead author R. Paul Wadwa, MD, of the Barbara Davis Center for Diabetes, University of Colorado at Denver, Aurora, and colleagues wrote.

Thus far in the United States, only the Medtronic MiniMed 770G and the Omnipod 5 automated insulin delivery systems are approved for children as young as 2 years, they noted.

In the current study of 102 children with type 1 diabetes aged at least 2 years but younger than 6 years, time-in-range over 13 weeks was higher for those randomized to the hybrid closed-loop system, compared with standard of care; the latter included either an insulin pump or multiple daily injections plus a separate Dexcom G6 CGM.

The hybrid closed-loop system added an average of about 3 hours in ideal blood glucose range over the 13 weeks, compared with no change with standard care.

Moreover, the trial was conducted during the COVID-19 pandemic, necessitating virtual care for most of the study participants. As a result, more than 80% of the training on use of the system and over 90% of all the visits were conducted virtually.

“Successful use of the closed-loop system under these conditions is an important finding that could affect the approach to initiating and monitoring the use of the closed-loop system and expand the use of such systems, particularly in patients living in areas without an endocrinologist but with reliable internet access,” the investigators wrote.

Their findings were published online in the New England Journal of Medicine.

“These results suggest that, in very young children, closed-loop systems are superior to standard care with respect to glucose control,” Daniela Bruttomesso, MD, PhD, of the University of Padua (Italy) wrote in an accompanying editorial.

“Moreover, they show that the closed-loop system can be started remotely in children in this age range, with results that are similar to those obtained when parents or guardians receive face-to-face education about the use of these systems. The closed-loop system used in this trial appeared to be safe and effective.”

Dr. Bruttomesso added: “Although the results were solid, the trial period was only 13 weeks, and there were more unscheduled contacts in the closed-loop group than in the standard care group. In addition, the authors compared a closed-loop system with standard care, rather than in-person initiation of a closed-loop system with remote initiation.”
 

More time-in-range, no hypoglycemia with automated system

The 102 children were enrolled in the trial between April 28, 2021, and Jan. 13, 2022, at three different U.S. study sites; 68 children were randomized to the closed-loop system and 34 children to standard care. All but one participant completed the 13-week study.

Both groups had virtual or in-person trial visits at 2, 6, and 13 weeks after randomization, and telephone contact at 1 and 10 weeks. Training was virtual for 55 of the 68 children in the closed-loop group (81%). A total of 91% of 407 study visits in the closed-loop and 96% of 204 study visits in the standard-care group were also virtual.

The mean percentage of time spent in target glucose range (70-180 mg/dL) increased from 56.9% at baseline to 69.3% at 13 weeks for the closed-loop group, compared with virtually no change, from 54.9% to 55.9%, in the standard-care group. The mean adjusted difference between the two groups was significant (P < .001).

The closed-loop group also spent significantly less time than the standard-care group with glucose levels above 250 mg/dL during the study period (8.4% vs. 15.0%; P < .001), had lower mean glucose levels (155 vs. 174 mg/dL; P < .001), and lower hemoglobin A1c (7.0% vs. 7.5%; P < .001).

However, time spent with glucose levels below 70 mg/dL (3.0% vs. 3.0%; P = .57) and below 54 mg/dL (0.6% vs. 0.5%) didn’t differ between the groups. 

There were two cases of severe hypoglycemia in the closed-loop group and one in the standard-care group. One case of diabetic ketoacidosis related to infusion set failure occurred in the closed-loop group versus none in the standard-care group.

Dr. Bruttomesso commented that a virtual approach has several advantages over in-person visits, including “a more relaxed environment, lower travel costs, and greater ease of contact with clinicians.”

At the same time, though, “patient preferences, possible legal issues, and accessibility to technology ... are all important considerations in choosing the most appropriate way to communicate with patients at the initiation of a closed-loop system or during routine follow-up.” The families of the patients in this trial had above-average incomes, she pointed out.

Ultimately, she said, “A mix of face-to-face visits and virtual clinic meetings may become routine in the management of diabetes in young children.”

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Wadwa reported receiving grants/contracts from Beta Bionics, Dexcom, Eli Lilly, and MannKind, travel fees from Eli Lilly, and lecture fees from Tandem Diabetes Care, and serves as a consultant for Dexcom. Dr. Bruttomesso reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A hybrid closed-loop automated insulin delivery system improved time-in-range for blood glucose, compared with standard care, for children with type 1 diabetes in a 13-week trial.

The hybrid closed-loop system, also called automated insulin delivery or artificial pancreas, was composed of a t:slim X2 insulin pump, a Dexcom G6 continuous glucose monitor (CGM), and Control-IQ technology system algorithm software (Tandem Diabetes Care). The system was approved in the United States in 2018 for adults and children as young as 6 years.

Type 1 diabetes treatment is particularly challenging in children younger than 6 because of their small insulin dosing requirements and unpredictable eating and activity habits, lead author R. Paul Wadwa, MD, of the Barbara Davis Center for Diabetes, University of Colorado at Denver, Aurora, and colleagues wrote.

Thus far in the United States, only the Medtronic MiniMed 770G and the Omnipod 5 automated insulin delivery systems are approved for children as young as 2 years, they noted.

In the current study of 102 children with type 1 diabetes aged at least 2 years but younger than 6 years, time-in-range over 13 weeks was higher for those randomized to the hybrid closed-loop system, compared with standard of care; the latter included either an insulin pump or multiple daily injections plus a separate Dexcom G6 CGM.

The hybrid closed-loop system added an average of about 3 hours in ideal blood glucose range over the 13 weeks, compared with no change with standard care.

Moreover, the trial was conducted during the COVID-19 pandemic, necessitating virtual care for most of the study participants. As a result, more than 80% of the training on use of the system and over 90% of all the visits were conducted virtually.

“Successful use of the closed-loop system under these conditions is an important finding that could affect the approach to initiating and monitoring the use of the closed-loop system and expand the use of such systems, particularly in patients living in areas without an endocrinologist but with reliable internet access,” the investigators wrote.

Their findings were published online in the New England Journal of Medicine.

“These results suggest that, in very young children, closed-loop systems are superior to standard care with respect to glucose control,” Daniela Bruttomesso, MD, PhD, of the University of Padua (Italy) wrote in an accompanying editorial.

“Moreover, they show that the closed-loop system can be started remotely in children in this age range, with results that are similar to those obtained when parents or guardians receive face-to-face education about the use of these systems. The closed-loop system used in this trial appeared to be safe and effective.”

Dr. Bruttomesso added: “Although the results were solid, the trial period was only 13 weeks, and there were more unscheduled contacts in the closed-loop group than in the standard care group. In addition, the authors compared a closed-loop system with standard care, rather than in-person initiation of a closed-loop system with remote initiation.”
 

More time-in-range, no hypoglycemia with automated system

The 102 children were enrolled in the trial between April 28, 2021, and Jan. 13, 2022, at three different U.S. study sites; 68 children were randomized to the closed-loop system and 34 children to standard care. All but one participant completed the 13-week study.

Both groups had virtual or in-person trial visits at 2, 6, and 13 weeks after randomization, and telephone contact at 1 and 10 weeks. Training was virtual for 55 of the 68 children in the closed-loop group (81%). A total of 91% of 407 study visits in the closed-loop and 96% of 204 study visits in the standard-care group were also virtual.

The mean percentage of time spent in target glucose range (70-180 mg/dL) increased from 56.9% at baseline to 69.3% at 13 weeks for the closed-loop group, compared with virtually no change, from 54.9% to 55.9%, in the standard-care group. The mean adjusted difference between the two groups was significant (P < .001).

The closed-loop group also spent significantly less time than the standard-care group with glucose levels above 250 mg/dL during the study period (8.4% vs. 15.0%; P < .001), had lower mean glucose levels (155 vs. 174 mg/dL; P < .001), and lower hemoglobin A1c (7.0% vs. 7.5%; P < .001).

However, time spent with glucose levels below 70 mg/dL (3.0% vs. 3.0%; P = .57) and below 54 mg/dL (0.6% vs. 0.5%) didn’t differ between the groups. 

There were two cases of severe hypoglycemia in the closed-loop group and one in the standard-care group. One case of diabetic ketoacidosis related to infusion set failure occurred in the closed-loop group versus none in the standard-care group.

Dr. Bruttomesso commented that a virtual approach has several advantages over in-person visits, including “a more relaxed environment, lower travel costs, and greater ease of contact with clinicians.”

At the same time, though, “patient preferences, possible legal issues, and accessibility to technology ... are all important considerations in choosing the most appropriate way to communicate with patients at the initiation of a closed-loop system or during routine follow-up.” The families of the patients in this trial had above-average incomes, she pointed out.

Ultimately, she said, “A mix of face-to-face visits and virtual clinic meetings may become routine in the management of diabetes in young children.”

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Wadwa reported receiving grants/contracts from Beta Bionics, Dexcom, Eli Lilly, and MannKind, travel fees from Eli Lilly, and lecture fees from Tandem Diabetes Care, and serves as a consultant for Dexcom. Dr. Bruttomesso reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A hybrid closed-loop automated insulin delivery system improved time-in-range for blood glucose, compared with standard care, for children with type 1 diabetes in a 13-week trial.

The hybrid closed-loop system, also called automated insulin delivery or artificial pancreas, was composed of a t:slim X2 insulin pump, a Dexcom G6 continuous glucose monitor (CGM), and Control-IQ technology system algorithm software (Tandem Diabetes Care). The system was approved in the United States in 2018 for adults and children as young as 6 years.

Type 1 diabetes treatment is particularly challenging in children younger than 6 because of their small insulin dosing requirements and unpredictable eating and activity habits, lead author R. Paul Wadwa, MD, of the Barbara Davis Center for Diabetes, University of Colorado at Denver, Aurora, and colleagues wrote.

Thus far in the United States, only the Medtronic MiniMed 770G and the Omnipod 5 automated insulin delivery systems are approved for children as young as 2 years, they noted.

In the current study of 102 children with type 1 diabetes aged at least 2 years but younger than 6 years, time-in-range over 13 weeks was higher for those randomized to the hybrid closed-loop system, compared with standard of care; the latter included either an insulin pump or multiple daily injections plus a separate Dexcom G6 CGM.

The hybrid closed-loop system added an average of about 3 hours in ideal blood glucose range over the 13 weeks, compared with no change with standard care.

Moreover, the trial was conducted during the COVID-19 pandemic, necessitating virtual care for most of the study participants. As a result, more than 80% of the training on use of the system and over 90% of all the visits were conducted virtually.

“Successful use of the closed-loop system under these conditions is an important finding that could affect the approach to initiating and monitoring the use of the closed-loop system and expand the use of such systems, particularly in patients living in areas without an endocrinologist but with reliable internet access,” the investigators wrote.

Their findings were published online in the New England Journal of Medicine.

“These results suggest that, in very young children, closed-loop systems are superior to standard care with respect to glucose control,” Daniela Bruttomesso, MD, PhD, of the University of Padua (Italy) wrote in an accompanying editorial.

“Moreover, they show that the closed-loop system can be started remotely in children in this age range, with results that are similar to those obtained when parents or guardians receive face-to-face education about the use of these systems. The closed-loop system used in this trial appeared to be safe and effective.”

Dr. Bruttomesso added: “Although the results were solid, the trial period was only 13 weeks, and there were more unscheduled contacts in the closed-loop group than in the standard care group. In addition, the authors compared a closed-loop system with standard care, rather than in-person initiation of a closed-loop system with remote initiation.”
 

More time-in-range, no hypoglycemia with automated system

The 102 children were enrolled in the trial between April 28, 2021, and Jan. 13, 2022, at three different U.S. study sites; 68 children were randomized to the closed-loop system and 34 children to standard care. All but one participant completed the 13-week study.

Both groups had virtual or in-person trial visits at 2, 6, and 13 weeks after randomization, and telephone contact at 1 and 10 weeks. Training was virtual for 55 of the 68 children in the closed-loop group (81%). A total of 91% of 407 study visits in the closed-loop and 96% of 204 study visits in the standard-care group were also virtual.

The mean percentage of time spent in target glucose range (70-180 mg/dL) increased from 56.9% at baseline to 69.3% at 13 weeks for the closed-loop group, compared with virtually no change, from 54.9% to 55.9%, in the standard-care group. The mean adjusted difference between the two groups was significant (P < .001).

The closed-loop group also spent significantly less time than the standard-care group with glucose levels above 250 mg/dL during the study period (8.4% vs. 15.0%; P < .001), had lower mean glucose levels (155 vs. 174 mg/dL; P < .001), and lower hemoglobin A1c (7.0% vs. 7.5%; P < .001).

However, time spent with glucose levels below 70 mg/dL (3.0% vs. 3.0%; P = .57) and below 54 mg/dL (0.6% vs. 0.5%) didn’t differ between the groups. 

There were two cases of severe hypoglycemia in the closed-loop group and one in the standard-care group. One case of diabetic ketoacidosis related to infusion set failure occurred in the closed-loop group versus none in the standard-care group.

Dr. Bruttomesso commented that a virtual approach has several advantages over in-person visits, including “a more relaxed environment, lower travel costs, and greater ease of contact with clinicians.”

At the same time, though, “patient preferences, possible legal issues, and accessibility to technology ... are all important considerations in choosing the most appropriate way to communicate with patients at the initiation of a closed-loop system or during routine follow-up.” The families of the patients in this trial had above-average incomes, she pointed out.

Ultimately, she said, “A mix of face-to-face visits and virtual clinic meetings may become routine in the management of diabetes in young children.”

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Wadwa reported receiving grants/contracts from Beta Bionics, Dexcom, Eli Lilly, and MannKind, travel fees from Eli Lilly, and lecture fees from Tandem Diabetes Care, and serves as a consultant for Dexcom. Dr. Bruttomesso reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Physicians are admired for their sacrifice and dedication. Yet beneath the surface lies a painful, quiet reality: Physicians take their lives more than any other professional, reported at 40 per 100,000. Nearly one doctor dies by suicide every day.

The Physicians Foundation says that 55% of physicians know a doctor who considered, attempted, or died by suicide. Doctor’s Burden: Medscape Physician Suicide Report 2023 asked more than 9,000 doctors if they had suicidal thoughts. Nine percent of male physicians and 11% of female physicians said yes.
 

Why do so many doctors take their own lives?

“It’s not a new phenomenon,” says Rajnish Jaiswal, MD, associate chief of emergency medicine at NYC H+H Metropolitan Hospital and assistant professor of emergency medicine at New York Medical College. “There was a paper 150 years ago, published in England, which commented on the high rates of physician suicides compared to other professionals, and that trend has continued.”

Dr. Jaiswal says that the feeling in the physician community is that the numbers are even higher than what’s reported, unfortunately, which is an opinion echoed by other doctors this news organization spoke with for this story.
 

A perfect storm

Jodie Eckleberry-Hunt, PhD, a board-certified health psychologist, executive coach, and author, says the most significant culprit historically may be a rigid mindset that many physicians have. “There’s black and white, there’s a right answer and a wrong answer, there’s good and bad, and some physicians have a really hard time flexing,” she says.

Psychological flexibility underlies resilience. Dr. Eckleberry-Hunt says, “Think about your bounce factor and how that resilience is protective. Life isn’t always going to go well. You have to be able to flex and bounce, and some physicians (not all of them, of course) tend to be lower on cognitive flexibility.”

Brad Fern, coach and psychotherapist at Fern Executive and Physician Consulting, Minneapolis, says he uses two analogies that help when he works with physicians. One is the evil twins, and the other is the pressure cooker.

Mr. Fern says that the evil twins are silence and isolation and that several professions, including physicians, fall prey to these. To put any dent in suicidal ideations and suicide, Mr. Fern says, these must be addressed.

“Physicians tend not to talk about what’s bothering them, and that’s for many different reasons. They disproportionally tend to be great at helping other people but not great at receiving help themselves.”

On top of that, there’s a pressure cooker where they work. Mr. Fern doesn’t think anyone would argue that the health care system in the United States is not dysfunctional, at least to some degree. He says that this dysfunction acts like the physicians’ pressure cooker.

Add in circumstances, cultures, and day-to-day issues everyone has, like relational issues, parenting issues, and mental health problems. Then, toss in an individual’s lower resiliency, the inability to receive help, and a predicament for good measure – a loss, a divorce, or financial woes, for instance, which can overwhelm. Mr. Fern says it can be a mathematical equation for suicidal ideation.
 

Is there a why?

“Some people think there’s a reason for suicide, but often, there’s a spectrum of reasons,” says Mr. Fern. He says that some physicians are trying to escape emotional pain. For others, it can be fear or a revenge thing, like, “the hell with you, I’m going to kill myself.” It can be getting attention the way teens do, as professionals have seen. Then there’s the organic component, like brain trauma, brain imbalance, depression, anxiety, or bipolar disorder. And finally, a drug or alcohol issue.

“But the reason why physician suicide is elevated, I think, is because there’s this ethos around being silent and, ‘I’m going to listen to and solve everyone else’s problems, but I’m not going to reach out and get help for my own,’ ” says Mr. Fern. “If you take advantage of mental health services, you’re implying that you’re mentally ill. And most physicians aren’t going to do that.”

On the positive side, Dr. Eckleberry-Hunt says that she sees many younger physicians discussing trauma. As a result, they’re more open to receiving help than previous generations. She speculates whether physicians have always had trauma from their past and whether current-day issues are now triggering it or whether they have more trauma these days. “Are they talking about it more, or is it experienced more?”
 

The failure of the system

The building blocks for physician suicide may have been there from the beginning. “From your first day of medical school and throughout your career, there was a very rigid system in place that is quite unforgiving, is quite stressful, and demands a lot,” says Dr. Jaiswal. And it’s within this system that physicians must operate.

“You have all the corporations, entities, organizations, [and] medical societies talking about physician wellness, burnout, and suicide, but the reality is it’s not making that much of a difference,” he says.

In her report, “What I’ve Learned From 1,710 Doctor Suicides,” Pamelia Wible, MD, who runs a physician suicide helpline that physicians can email and get an immediate callback, likens the current system to assembly line medicine.

Dr. Eckleberry-Hunt thinks the message has been bungled in health care. Everyone discusses burnout, meditation, self-care, and other essential constructs. “But we don’t deal with the root cause [of suicide]. Instead, we teach you soothing strategies.”

Further, Dr. Jaiswal says that not all physicians who commit suicide experience burnout or are experiencing burnout and that the vast majority of physicians who experience burnout don’t have suicidal ideation. “In the sense, that ‘let’s address physician burnout and that will hopefully translate to a reduced number of physician suicides’ – there is a very tenuous argument to be made for that because that is just one aspect in this complex system,” he says.
 

We need more than just lip service on suicide

Overall, the experts interviewed for this article acknowledged that the system is at least talking about physician suicide, which is a big first step. However, most agree that where big health entities go wrong is that they set up wellness or mental health programs, they implement a wellness officer, they write up talking points for physicians who need mental health care to get that care, and they think they’ve done their job, that they’ve done what’s required to address the problem.

But Dr. Jaiswal thinks these are often mostly public-relations rebuttals. Mr. Fern suggests, “It’s a show that’s not effective.” And Dr. Eckleberry-Hunt says that “even if you had a legit, well-funded well-being program for health care providers, you would still have a baseline rate of physician suicide, and that gets down to having drug and alcohol education and talking about having a system for physicians to access that doesn’t come along with insurance billing” – one that doesn’t create a paper trail and follow physician licensure and job applications for the rest of their career; one that doesn’t associate their mental health care with their work institution; one that offers confidentiality.

“For most folks, there is still a big distrust in the system. As physicians, very few of them feel that the system that they’re operating in has their best interest at heart. And that is why very few physicians will self-report any mental health issues, depression, or even ideation to colleagues, superiors, or managers,” says Dr. Jaiswal. Many more feel skeptical about the confidentiality of the programs in place.

The experts acknowledge that many people are trying to work on this and bring about change on multiple levels – grassroots, department levels, state, and federal. “But I think the biggest thing that the system has to do is earn back the trust of the physician,” Dr. Jaiswal adds.

“Physician suicide is a very visible problem in a very broken system. So, it’ll be very difficult in isolation to treat it without making any systemic changes, because that’s happening right now, and it’s not working,” says Dr. Jaiswal.

“The thing that I am most hopeful about is that I am seeing an influx of younger physicians who seek me out, and granted, their training programs tell them to come and see me, but they are ready and willing to talk about their mental health separate from work. They’re not coming in saying, ‘Here are all the people who I blame.’ They’re saying, ‘These are my struggles, and I want to be a better, happier physician,’ ” says Dr. Eckleberry-Hunt.

A version of this article originally appeared on Medscape.com.

Physicians are admired for their sacrifice and dedication. Yet beneath the surface lies a painful, quiet reality: Physicians take their lives more than any other professional, reported at 40 per 100,000. Nearly one doctor dies by suicide every day.

The Physicians Foundation says that 55% of physicians know a doctor who considered, attempted, or died by suicide. Doctor’s Burden: Medscape Physician Suicide Report 2023 asked more than 9,000 doctors if they had suicidal thoughts. Nine percent of male physicians and 11% of female physicians said yes.
 

Why do so many doctors take their own lives?

“It’s not a new phenomenon,” says Rajnish Jaiswal, MD, associate chief of emergency medicine at NYC H+H Metropolitan Hospital and assistant professor of emergency medicine at New York Medical College. “There was a paper 150 years ago, published in England, which commented on the high rates of physician suicides compared to other professionals, and that trend has continued.”

Dr. Jaiswal says that the feeling in the physician community is that the numbers are even higher than what’s reported, unfortunately, which is an opinion echoed by other doctors this news organization spoke with for this story.
 

A perfect storm

Jodie Eckleberry-Hunt, PhD, a board-certified health psychologist, executive coach, and author, says the most significant culprit historically may be a rigid mindset that many physicians have. “There’s black and white, there’s a right answer and a wrong answer, there’s good and bad, and some physicians have a really hard time flexing,” she says.

Psychological flexibility underlies resilience. Dr. Eckleberry-Hunt says, “Think about your bounce factor and how that resilience is protective. Life isn’t always going to go well. You have to be able to flex and bounce, and some physicians (not all of them, of course) tend to be lower on cognitive flexibility.”

Brad Fern, coach and psychotherapist at Fern Executive and Physician Consulting, Minneapolis, says he uses two analogies that help when he works with physicians. One is the evil twins, and the other is the pressure cooker.

Mr. Fern says that the evil twins are silence and isolation and that several professions, including physicians, fall prey to these. To put any dent in suicidal ideations and suicide, Mr. Fern says, these must be addressed.

“Physicians tend not to talk about what’s bothering them, and that’s for many different reasons. They disproportionally tend to be great at helping other people but not great at receiving help themselves.”

On top of that, there’s a pressure cooker where they work. Mr. Fern doesn’t think anyone would argue that the health care system in the United States is not dysfunctional, at least to some degree. He says that this dysfunction acts like the physicians’ pressure cooker.

Add in circumstances, cultures, and day-to-day issues everyone has, like relational issues, parenting issues, and mental health problems. Then, toss in an individual’s lower resiliency, the inability to receive help, and a predicament for good measure – a loss, a divorce, or financial woes, for instance, which can overwhelm. Mr. Fern says it can be a mathematical equation for suicidal ideation.
 

Is there a why?

“Some people think there’s a reason for suicide, but often, there’s a spectrum of reasons,” says Mr. Fern. He says that some physicians are trying to escape emotional pain. For others, it can be fear or a revenge thing, like, “the hell with you, I’m going to kill myself.” It can be getting attention the way teens do, as professionals have seen. Then there’s the organic component, like brain trauma, brain imbalance, depression, anxiety, or bipolar disorder. And finally, a drug or alcohol issue.

“But the reason why physician suicide is elevated, I think, is because there’s this ethos around being silent and, ‘I’m going to listen to and solve everyone else’s problems, but I’m not going to reach out and get help for my own,’ ” says Mr. Fern. “If you take advantage of mental health services, you’re implying that you’re mentally ill. And most physicians aren’t going to do that.”

On the positive side, Dr. Eckleberry-Hunt says that she sees many younger physicians discussing trauma. As a result, they’re more open to receiving help than previous generations. She speculates whether physicians have always had trauma from their past and whether current-day issues are now triggering it or whether they have more trauma these days. “Are they talking about it more, or is it experienced more?”
 

The failure of the system

The building blocks for physician suicide may have been there from the beginning. “From your first day of medical school and throughout your career, there was a very rigid system in place that is quite unforgiving, is quite stressful, and demands a lot,” says Dr. Jaiswal. And it’s within this system that physicians must operate.

“You have all the corporations, entities, organizations, [and] medical societies talking about physician wellness, burnout, and suicide, but the reality is it’s not making that much of a difference,” he says.

In her report, “What I’ve Learned From 1,710 Doctor Suicides,” Pamelia Wible, MD, who runs a physician suicide helpline that physicians can email and get an immediate callback, likens the current system to assembly line medicine.

Dr. Eckleberry-Hunt thinks the message has been bungled in health care. Everyone discusses burnout, meditation, self-care, and other essential constructs. “But we don’t deal with the root cause [of suicide]. Instead, we teach you soothing strategies.”

Further, Dr. Jaiswal says that not all physicians who commit suicide experience burnout or are experiencing burnout and that the vast majority of physicians who experience burnout don’t have suicidal ideation. “In the sense, that ‘let’s address physician burnout and that will hopefully translate to a reduced number of physician suicides’ – there is a very tenuous argument to be made for that because that is just one aspect in this complex system,” he says.
 

We need more than just lip service on suicide

Overall, the experts interviewed for this article acknowledged that the system is at least talking about physician suicide, which is a big first step. However, most agree that where big health entities go wrong is that they set up wellness or mental health programs, they implement a wellness officer, they write up talking points for physicians who need mental health care to get that care, and they think they’ve done their job, that they’ve done what’s required to address the problem.

But Dr. Jaiswal thinks these are often mostly public-relations rebuttals. Mr. Fern suggests, “It’s a show that’s not effective.” And Dr. Eckleberry-Hunt says that “even if you had a legit, well-funded well-being program for health care providers, you would still have a baseline rate of physician suicide, and that gets down to having drug and alcohol education and talking about having a system for physicians to access that doesn’t come along with insurance billing” – one that doesn’t create a paper trail and follow physician licensure and job applications for the rest of their career; one that doesn’t associate their mental health care with their work institution; one that offers confidentiality.

“For most folks, there is still a big distrust in the system. As physicians, very few of them feel that the system that they’re operating in has their best interest at heart. And that is why very few physicians will self-report any mental health issues, depression, or even ideation to colleagues, superiors, or managers,” says Dr. Jaiswal. Many more feel skeptical about the confidentiality of the programs in place.

The experts acknowledge that many people are trying to work on this and bring about change on multiple levels – grassroots, department levels, state, and federal. “But I think the biggest thing that the system has to do is earn back the trust of the physician,” Dr. Jaiswal adds.

“Physician suicide is a very visible problem in a very broken system. So, it’ll be very difficult in isolation to treat it without making any systemic changes, because that’s happening right now, and it’s not working,” says Dr. Jaiswal.

“The thing that I am most hopeful about is that I am seeing an influx of younger physicians who seek me out, and granted, their training programs tell them to come and see me, but they are ready and willing to talk about their mental health separate from work. They’re not coming in saying, ‘Here are all the people who I blame.’ They’re saying, ‘These are my struggles, and I want to be a better, happier physician,’ ” says Dr. Eckleberry-Hunt.

A version of this article originally appeared on Medscape.com.

Physicians are admired for their sacrifice and dedication. Yet beneath the surface lies a painful, quiet reality: Physicians take their lives more than any other professional, reported at 40 per 100,000. Nearly one doctor dies by suicide every day.

The Physicians Foundation says that 55% of physicians know a doctor who considered, attempted, or died by suicide. Doctor’s Burden: Medscape Physician Suicide Report 2023 asked more than 9,000 doctors if they had suicidal thoughts. Nine percent of male physicians and 11% of female physicians said yes.
 

Why do so many doctors take their own lives?

“It’s not a new phenomenon,” says Rajnish Jaiswal, MD, associate chief of emergency medicine at NYC H+H Metropolitan Hospital and assistant professor of emergency medicine at New York Medical College. “There was a paper 150 years ago, published in England, which commented on the high rates of physician suicides compared to other professionals, and that trend has continued.”

Dr. Jaiswal says that the feeling in the physician community is that the numbers are even higher than what’s reported, unfortunately, which is an opinion echoed by other doctors this news organization spoke with for this story.
 

A perfect storm

Jodie Eckleberry-Hunt, PhD, a board-certified health psychologist, executive coach, and author, says the most significant culprit historically may be a rigid mindset that many physicians have. “There’s black and white, there’s a right answer and a wrong answer, there’s good and bad, and some physicians have a really hard time flexing,” she says.

Psychological flexibility underlies resilience. Dr. Eckleberry-Hunt says, “Think about your bounce factor and how that resilience is protective. Life isn’t always going to go well. You have to be able to flex and bounce, and some physicians (not all of them, of course) tend to be lower on cognitive flexibility.”

Brad Fern, coach and psychotherapist at Fern Executive and Physician Consulting, Minneapolis, says he uses two analogies that help when he works with physicians. One is the evil twins, and the other is the pressure cooker.

Mr. Fern says that the evil twins are silence and isolation and that several professions, including physicians, fall prey to these. To put any dent in suicidal ideations and suicide, Mr. Fern says, these must be addressed.

“Physicians tend not to talk about what’s bothering them, and that’s for many different reasons. They disproportionally tend to be great at helping other people but not great at receiving help themselves.”

On top of that, there’s a pressure cooker where they work. Mr. Fern doesn’t think anyone would argue that the health care system in the United States is not dysfunctional, at least to some degree. He says that this dysfunction acts like the physicians’ pressure cooker.

Add in circumstances, cultures, and day-to-day issues everyone has, like relational issues, parenting issues, and mental health problems. Then, toss in an individual’s lower resiliency, the inability to receive help, and a predicament for good measure – a loss, a divorce, or financial woes, for instance, which can overwhelm. Mr. Fern says it can be a mathematical equation for suicidal ideation.
 

Is there a why?

“Some people think there’s a reason for suicide, but often, there’s a spectrum of reasons,” says Mr. Fern. He says that some physicians are trying to escape emotional pain. For others, it can be fear or a revenge thing, like, “the hell with you, I’m going to kill myself.” It can be getting attention the way teens do, as professionals have seen. Then there’s the organic component, like brain trauma, brain imbalance, depression, anxiety, or bipolar disorder. And finally, a drug or alcohol issue.

“But the reason why physician suicide is elevated, I think, is because there’s this ethos around being silent and, ‘I’m going to listen to and solve everyone else’s problems, but I’m not going to reach out and get help for my own,’ ” says Mr. Fern. “If you take advantage of mental health services, you’re implying that you’re mentally ill. And most physicians aren’t going to do that.”

On the positive side, Dr. Eckleberry-Hunt says that she sees many younger physicians discussing trauma. As a result, they’re more open to receiving help than previous generations. She speculates whether physicians have always had trauma from their past and whether current-day issues are now triggering it or whether they have more trauma these days. “Are they talking about it more, or is it experienced more?”
 

The failure of the system

The building blocks for physician suicide may have been there from the beginning. “From your first day of medical school and throughout your career, there was a very rigid system in place that is quite unforgiving, is quite stressful, and demands a lot,” says Dr. Jaiswal. And it’s within this system that physicians must operate.

“You have all the corporations, entities, organizations, [and] medical societies talking about physician wellness, burnout, and suicide, but the reality is it’s not making that much of a difference,” he says.

In her report, “What I’ve Learned From 1,710 Doctor Suicides,” Pamelia Wible, MD, who runs a physician suicide helpline that physicians can email and get an immediate callback, likens the current system to assembly line medicine.

Dr. Eckleberry-Hunt thinks the message has been bungled in health care. Everyone discusses burnout, meditation, self-care, and other essential constructs. “But we don’t deal with the root cause [of suicide]. Instead, we teach you soothing strategies.”

Further, Dr. Jaiswal says that not all physicians who commit suicide experience burnout or are experiencing burnout and that the vast majority of physicians who experience burnout don’t have suicidal ideation. “In the sense, that ‘let’s address physician burnout and that will hopefully translate to a reduced number of physician suicides’ – there is a very tenuous argument to be made for that because that is just one aspect in this complex system,” he says.
 

We need more than just lip service on suicide

Overall, the experts interviewed for this article acknowledged that the system is at least talking about physician suicide, which is a big first step. However, most agree that where big health entities go wrong is that they set up wellness or mental health programs, they implement a wellness officer, they write up talking points for physicians who need mental health care to get that care, and they think they’ve done their job, that they’ve done what’s required to address the problem.

But Dr. Jaiswal thinks these are often mostly public-relations rebuttals. Mr. Fern suggests, “It’s a show that’s not effective.” And Dr. Eckleberry-Hunt says that “even if you had a legit, well-funded well-being program for health care providers, you would still have a baseline rate of physician suicide, and that gets down to having drug and alcohol education and talking about having a system for physicians to access that doesn’t come along with insurance billing” – one that doesn’t create a paper trail and follow physician licensure and job applications for the rest of their career; one that doesn’t associate their mental health care with their work institution; one that offers confidentiality.

“For most folks, there is still a big distrust in the system. As physicians, very few of them feel that the system that they’re operating in has their best interest at heart. And that is why very few physicians will self-report any mental health issues, depression, or even ideation to colleagues, superiors, or managers,” says Dr. Jaiswal. Many more feel skeptical about the confidentiality of the programs in place.

The experts acknowledge that many people are trying to work on this and bring about change on multiple levels – grassroots, department levels, state, and federal. “But I think the biggest thing that the system has to do is earn back the trust of the physician,” Dr. Jaiswal adds.

“Physician suicide is a very visible problem in a very broken system. So, it’ll be very difficult in isolation to treat it without making any systemic changes, because that’s happening right now, and it’s not working,” says Dr. Jaiswal.

“The thing that I am most hopeful about is that I am seeing an influx of younger physicians who seek me out, and granted, their training programs tell them to come and see me, but they are ready and willing to talk about their mental health separate from work. They’re not coming in saying, ‘Here are all the people who I blame.’ They’re saying, ‘These are my struggles, and I want to be a better, happier physician,’ ” says Dr. Eckleberry-Hunt.

A version of this article originally appeared on Medscape.com.

A new oral formulation of a PCSK9-inhibiting, cholesterol-lowering drug in development by Merck has shown encouraging results in a phase 2 study.

The study was presented by Christie Ballantyne, MD, Baylor College of Medicine, Houston, at the joint scientific sessions of the American College of Cardiology and the World Heart Federation.

Mitchel L. Zoler/MDedge News

“In this diverse population of hypercholesterolemic patients, all doses of MK-0616 showed superior reduction of LDL vs. placebo up to a 60.9% placebo-adjusted reduction from baseline to week 8, which was consistent across subgroups,” Dr. Ballantyne reported.

“Reduction in ApoB and non-HDL cholesterol were consistent with that of LDL cholesterol, with up to a 51.8% reduction in ApoB and a 55.8% reduction in non-HDL,” he noted.  

He added that the drug was well tolerated with no difference in adverse events across the treatment groups, compared with placebo.

“These data support the further development of MK-0616, an oral PCSK9 inhibitor that may improve access to effective LDL-cholesterol lowering therapies and improve attainment of guideline-recommended LDL goals aimed at reducing cardiovascular risk,” Dr. Ballantyne concluded. “The results are encouraging for a phase 3 program that is now being designed.”

He explained that elevated LDL is a primary causative factor for atherosclerotic cardiovascular disease (ASCVD), and despite effective treatments (statins), a large proportion of patients fail to achieve guideline-recommended LDL levels. Injectable treatments targeting PCSK9 have demonstrated large reductions in LDL and decreased risk of ASCVD events, but access barriers and need for repeat injections have led to poor adoption. An oral PCSK9 inhibitor may widen access and improve attainment of guideline-recommended treatment goals.

Dr. Ballantyne described the new drug, MK-0616, as a “macrocyclic peptide that can bind PCSK9 with monoclonal antibody-like affinity at 1/100th of the molecular weight.”

The current phase 2 study included 381 adult patients (49% female; median age 62 years) with a wide range of ASCVD risk. Average LDL-C level was 119.5 mg/dL at baseline. Around 40% of patients were not taking statins, 35% were on low- to moderate-intensity statin therapy, and 26% were on high-intensity statin therapy.

They were randomly assigned to four different doses of MK-0616 (6, 12, 18, or 30 mg once daily) or matching placebo.

Results showed that all doses of MK-0616 demonstrated statistically significant differences in percentage change in LDL-C from baseline to week 8 vs. placebo: –41.2% (6 mg), –55.7% (12 mg), –59.1% (18 mg), and –60.9% (30 mg).

The mean percentage changes in ApoB from baseline vs. placebo were –32.8%, –45.8%, –48.7%, and 51.8% for the four escalating doses of the drug. And non-HDL cholesterol changes were –35.9%, –50.5%, –53.2%, and –55.8% respectively.

The proportion of participants at protocol-defined goals for LDL reduction was 80.5%, 85.5%, 90.8%, and 90.8% with MK-0616 at the 6-mg, 12-mg, 18-mg, and 30-mg doses, compared with 9.3% with placebo.

Dr. Ballantyne reported that the efficacy looked similar in all subgroups, and regardless of baseline therapy. 

“This was a dose-finding study, which will help select a dose to be taken forward in larger studies, and it looks from these results as though you get most of the efficacy by 12 mg,” he added.  

Adverse events occurred in a proportion of participants in the MK-0616 groups (39.5% to 43.4%) similar to that of placebo (44.0%), and discontinuations as a result of adverse events occurred in two or fewer participants in any treatment group.
 

‘Super exciting’

Putting the results of his study into perspective at an ACC press conference, Rhonda Cooper-DeHoff, PharmD, associate professor in the department of pharmacotherapy and translational research at the University of Florida in Gainesville, commented.

Mitchel L. Zoler/MDedge News

“For the last quarter of a century we have had statins available to treat elevated LDL and atherosclerosis and despite that we have many patients who refuse to take statins or are afraid to take statins,” she said. “This is not about cost as the statins are all available generically now. But many patients claim to be intolerant or unresponsive.”

She noted that in 2015/2016 the first injectable PCSK9 inhibitors became available “which really were very exciting molecules, but they have a high cost and access issues, and patients often do not like injections so there are still a lot of issues.”

Dr. Cooper-DeHoff pointed out that this oral PCSK9 inhibitor seems to be as effective at lowering LDL as the injectable products regardless of whether statins are on board or not, which she said was “super exciting.”

She added: “We are all going to be waiting excitedly for the outcome data with this oral PCSK9 inhibitor.”

She also noted that another study (CLEAR Outcomes) presented at the ACC meeting showed good lipid-lowering results and a reduction in cardiovascular outcomes in statin-intolerant patients with another oral lipid lowering drug, bempedoic acid (Nexletol).

She said the two oral drugs promised a “very bright for the future for LDL lowering and the treatment of atherosclerosis in our patients,” adding that “we are now really chipping away at the barriers to achieving the holy grail of guideline-directed LDL lowering to prevent hard outcomes.”

The results were published online in the Journal of the American College of Cardiology at the time of presentation. 

This study was funded by Merck. Dr. Ballantyne has received grant/research support through his institution from Abbott Diagnostic, Akcea, Amgen, Arrowhead, Esperion, Ionis, Merck, New Amsterdam, Novartis, Novo Nordisk, Regeneron, and Roche Diagnostics and has been a consultant for 89Bio, Abbott Diagnostics, Alnylam Pharmaceuticals, Althera, Amarin, Amgen, Arrowhead, AstraZeneca, Denka Seiken, Esperion, Genentech, Gilead, Illumina, Ionis, Matinas BioPharma, Merck, New Amsterdam, Novartis, Novo Nordisk, Pfizer, Regeneron, and Roche Diagnostics.

A version of this article first appeared on Medscape.com.

A new oral formulation of a PCSK9-inhibiting, cholesterol-lowering drug in development by Merck has shown encouraging results in a phase 2 study.

The study was presented by Christie Ballantyne, MD, Baylor College of Medicine, Houston, at the joint scientific sessions of the American College of Cardiology and the World Heart Federation.

Mitchel L. Zoler/MDedge News

“In this diverse population of hypercholesterolemic patients, all doses of MK-0616 showed superior reduction of LDL vs. placebo up to a 60.9% placebo-adjusted reduction from baseline to week 8, which was consistent across subgroups,” Dr. Ballantyne reported.

“Reduction in ApoB and non-HDL cholesterol were consistent with that of LDL cholesterol, with up to a 51.8% reduction in ApoB and a 55.8% reduction in non-HDL,” he noted.  

He added that the drug was well tolerated with no difference in adverse events across the treatment groups, compared with placebo.

“These data support the further development of MK-0616, an oral PCSK9 inhibitor that may improve access to effective LDL-cholesterol lowering therapies and improve attainment of guideline-recommended LDL goals aimed at reducing cardiovascular risk,” Dr. Ballantyne concluded. “The results are encouraging for a phase 3 program that is now being designed.”

He explained that elevated LDL is a primary causative factor for atherosclerotic cardiovascular disease (ASCVD), and despite effective treatments (statins), a large proportion of patients fail to achieve guideline-recommended LDL levels. Injectable treatments targeting PCSK9 have demonstrated large reductions in LDL and decreased risk of ASCVD events, but access barriers and need for repeat injections have led to poor adoption. An oral PCSK9 inhibitor may widen access and improve attainment of guideline-recommended treatment goals.

Dr. Ballantyne described the new drug, MK-0616, as a “macrocyclic peptide that can bind PCSK9 with monoclonal antibody-like affinity at 1/100th of the molecular weight.”

The current phase 2 study included 381 adult patients (49% female; median age 62 years) with a wide range of ASCVD risk. Average LDL-C level was 119.5 mg/dL at baseline. Around 40% of patients were not taking statins, 35% were on low- to moderate-intensity statin therapy, and 26% were on high-intensity statin therapy.

They were randomly assigned to four different doses of MK-0616 (6, 12, 18, or 30 mg once daily) or matching placebo.

Results showed that all doses of MK-0616 demonstrated statistically significant differences in percentage change in LDL-C from baseline to week 8 vs. placebo: –41.2% (6 mg), –55.7% (12 mg), –59.1% (18 mg), and –60.9% (30 mg).

The mean percentage changes in ApoB from baseline vs. placebo were –32.8%, –45.8%, –48.7%, and 51.8% for the four escalating doses of the drug. And non-HDL cholesterol changes were –35.9%, –50.5%, –53.2%, and –55.8% respectively.

The proportion of participants at protocol-defined goals for LDL reduction was 80.5%, 85.5%, 90.8%, and 90.8% with MK-0616 at the 6-mg, 12-mg, 18-mg, and 30-mg doses, compared with 9.3% with placebo.

Dr. Ballantyne reported that the efficacy looked similar in all subgroups, and regardless of baseline therapy. 

“This was a dose-finding study, which will help select a dose to be taken forward in larger studies, and it looks from these results as though you get most of the efficacy by 12 mg,” he added.  

Adverse events occurred in a proportion of participants in the MK-0616 groups (39.5% to 43.4%) similar to that of placebo (44.0%), and discontinuations as a result of adverse events occurred in two or fewer participants in any treatment group.
 

‘Super exciting’

Putting the results of his study into perspective at an ACC press conference, Rhonda Cooper-DeHoff, PharmD, associate professor in the department of pharmacotherapy and translational research at the University of Florida in Gainesville, commented.

Mitchel L. Zoler/MDedge News

“For the last quarter of a century we have had statins available to treat elevated LDL and atherosclerosis and despite that we have many patients who refuse to take statins or are afraid to take statins,” she said. “This is not about cost as the statins are all available generically now. But many patients claim to be intolerant or unresponsive.”

She noted that in 2015/2016 the first injectable PCSK9 inhibitors became available “which really were very exciting molecules, but they have a high cost and access issues, and patients often do not like injections so there are still a lot of issues.”

Dr. Cooper-DeHoff pointed out that this oral PCSK9 inhibitor seems to be as effective at lowering LDL as the injectable products regardless of whether statins are on board or not, which she said was “super exciting.”

She added: “We are all going to be waiting excitedly for the outcome data with this oral PCSK9 inhibitor.”

She also noted that another study (CLEAR Outcomes) presented at the ACC meeting showed good lipid-lowering results and a reduction in cardiovascular outcomes in statin-intolerant patients with another oral lipid lowering drug, bempedoic acid (Nexletol).

She said the two oral drugs promised a “very bright for the future for LDL lowering and the treatment of atherosclerosis in our patients,” adding that “we are now really chipping away at the barriers to achieving the holy grail of guideline-directed LDL lowering to prevent hard outcomes.”

The results were published online in the Journal of the American College of Cardiology at the time of presentation. 

This study was funded by Merck. Dr. Ballantyne has received grant/research support through his institution from Abbott Diagnostic, Akcea, Amgen, Arrowhead, Esperion, Ionis, Merck, New Amsterdam, Novartis, Novo Nordisk, Regeneron, and Roche Diagnostics and has been a consultant for 89Bio, Abbott Diagnostics, Alnylam Pharmaceuticals, Althera, Amarin, Amgen, Arrowhead, AstraZeneca, Denka Seiken, Esperion, Genentech, Gilead, Illumina, Ionis, Matinas BioPharma, Merck, New Amsterdam, Novartis, Novo Nordisk, Pfizer, Regeneron, and Roche Diagnostics.

A version of this article first appeared on Medscape.com.

A new oral formulation of a PCSK9-inhibiting, cholesterol-lowering drug in development by Merck has shown encouraging results in a phase 2 study.

The study was presented by Christie Ballantyne, MD, Baylor College of Medicine, Houston, at the joint scientific sessions of the American College of Cardiology and the World Heart Federation.

Mitchel L. Zoler/MDedge News

“In this diverse population of hypercholesterolemic patients, all doses of MK-0616 showed superior reduction of LDL vs. placebo up to a 60.9% placebo-adjusted reduction from baseline to week 8, which was consistent across subgroups,” Dr. Ballantyne reported.

“Reduction in ApoB and non-HDL cholesterol were consistent with that of LDL cholesterol, with up to a 51.8% reduction in ApoB and a 55.8% reduction in non-HDL,” he noted.  

He added that the drug was well tolerated with no difference in adverse events across the treatment groups, compared with placebo.

“These data support the further development of MK-0616, an oral PCSK9 inhibitor that may improve access to effective LDL-cholesterol lowering therapies and improve attainment of guideline-recommended LDL goals aimed at reducing cardiovascular risk,” Dr. Ballantyne concluded. “The results are encouraging for a phase 3 program that is now being designed.”

He explained that elevated LDL is a primary causative factor for atherosclerotic cardiovascular disease (ASCVD), and despite effective treatments (statins), a large proportion of patients fail to achieve guideline-recommended LDL levels. Injectable treatments targeting PCSK9 have demonstrated large reductions in LDL and decreased risk of ASCVD events, but access barriers and need for repeat injections have led to poor adoption. An oral PCSK9 inhibitor may widen access and improve attainment of guideline-recommended treatment goals.

Dr. Ballantyne described the new drug, MK-0616, as a “macrocyclic peptide that can bind PCSK9 with monoclonal antibody-like affinity at 1/100th of the molecular weight.”

The current phase 2 study included 381 adult patients (49% female; median age 62 years) with a wide range of ASCVD risk. Average LDL-C level was 119.5 mg/dL at baseline. Around 40% of patients were not taking statins, 35% were on low- to moderate-intensity statin therapy, and 26% were on high-intensity statin therapy.

They were randomly assigned to four different doses of MK-0616 (6, 12, 18, or 30 mg once daily) or matching placebo.

Results showed that all doses of MK-0616 demonstrated statistically significant differences in percentage change in LDL-C from baseline to week 8 vs. placebo: –41.2% (6 mg), –55.7% (12 mg), –59.1% (18 mg), and –60.9% (30 mg).

The mean percentage changes in ApoB from baseline vs. placebo were –32.8%, –45.8%, –48.7%, and 51.8% for the four escalating doses of the drug. And non-HDL cholesterol changes were –35.9%, –50.5%, –53.2%, and –55.8% respectively.

The proportion of participants at protocol-defined goals for LDL reduction was 80.5%, 85.5%, 90.8%, and 90.8% with MK-0616 at the 6-mg, 12-mg, 18-mg, and 30-mg doses, compared with 9.3% with placebo.

Dr. Ballantyne reported that the efficacy looked similar in all subgroups, and regardless of baseline therapy. 

“This was a dose-finding study, which will help select a dose to be taken forward in larger studies, and it looks from these results as though you get most of the efficacy by 12 mg,” he added.  

Adverse events occurred in a proportion of participants in the MK-0616 groups (39.5% to 43.4%) similar to that of placebo (44.0%), and discontinuations as a result of adverse events occurred in two or fewer participants in any treatment group.
 

‘Super exciting’

Putting the results of his study into perspective at an ACC press conference, Rhonda Cooper-DeHoff, PharmD, associate professor in the department of pharmacotherapy and translational research at the University of Florida in Gainesville, commented.

Mitchel L. Zoler/MDedge News

“For the last quarter of a century we have had statins available to treat elevated LDL and atherosclerosis and despite that we have many patients who refuse to take statins or are afraid to take statins,” she said. “This is not about cost as the statins are all available generically now. But many patients claim to be intolerant or unresponsive.”

She noted that in 2015/2016 the first injectable PCSK9 inhibitors became available “which really were very exciting molecules, but they have a high cost and access issues, and patients often do not like injections so there are still a lot of issues.”

Dr. Cooper-DeHoff pointed out that this oral PCSK9 inhibitor seems to be as effective at lowering LDL as the injectable products regardless of whether statins are on board or not, which she said was “super exciting.”

She added: “We are all going to be waiting excitedly for the outcome data with this oral PCSK9 inhibitor.”

She also noted that another study (CLEAR Outcomes) presented at the ACC meeting showed good lipid-lowering results and a reduction in cardiovascular outcomes in statin-intolerant patients with another oral lipid lowering drug, bempedoic acid (Nexletol).

She said the two oral drugs promised a “very bright for the future for LDL lowering and the treatment of atherosclerosis in our patients,” adding that “we are now really chipping away at the barriers to achieving the holy grail of guideline-directed LDL lowering to prevent hard outcomes.”

The results were published online in the Journal of the American College of Cardiology at the time of presentation. 

This study was funded by Merck. Dr. Ballantyne has received grant/research support through his institution from Abbott Diagnostic, Akcea, Amgen, Arrowhead, Esperion, Ionis, Merck, New Amsterdam, Novartis, Novo Nordisk, Regeneron, and Roche Diagnostics and has been a consultant for 89Bio, Abbott Diagnostics, Alnylam Pharmaceuticals, Althera, Amarin, Amgen, Arrowhead, AstraZeneca, Denka Seiken, Esperion, Genentech, Gilead, Illumina, Ionis, Matinas BioPharma, Merck, New Amsterdam, Novartis, Novo Nordisk, Pfizer, Regeneron, and Roche Diagnostics.

A version of this article first appeared on Medscape.com.

High total intake of ultraprocessed food (UPF) is associated with an increased risk of developing type 2 diabetes, suggests a large-scale analysis that nevertheless revealed that the risk applies only to certain such foods.

Courtesy National Cancer Institute

The research was recently published in Diabetes Care by Zhangling Chen, PhD, Erasmus MC Rotterdam, Netherlands, and colleagues.

Examining almost 200,000 participants in three U.S. studies, yielding more than 5 million person-years of follow-up, the scientists found that high intake of UPF was associated with a 28% increased risk of type 2 diabetes, after statistical adjustments.

However, the increased risk was restricted to certain UPFs, including ready meals, refined breads, sweetened beverages, and sauces and condiments, with other foods considered UPFs, such as cereals, dark- and whole grain breads, and packaged sweet and savory snacks, among others, associated with a reduced risk of diabetes.

Senior author Jean-Philippe Drouin-Chartier, PhD, Nutrition Center, Laval University, Quebec City, told this news organization: “While whole grain breads can be considered as ultraprocessed foods, their consumption should not be discouraged. In our study, we observed that whole grain breads consumption is inversely associated with type 2 diabetes risk. This is supported by many studies linking dietary fiber consumption to better cardiometabolic health.”
 

Ultraprocessed food intake higher in the U.S. than in Europe

The researchers note that a handful of European studies have also reported an association between UPF consumption and increased type 2 diabetes risk, with the effect ranging from 15% to 53%, depending on the level of intake and the cohort of patients studied.

They note, however, that total UPF intake in the U.S. is “much higher than in Europe,” particularly in the case of ultraprocessed breads and cereals and artificially or sugar-sweetened beverages.

In the current study, they examined data on 71,781 women from the Nurses’ Health Study, 87,918 women from the NHS II, and 38,847 men from the Health Professional Follow-up Study, none of whom had cardiovascular disease, cancer, or diabetes at baseline.

In all three studies, questionnaires were administered every 2 years to collect demographic, lifestyle, and medical information, and a validated food frequency questionnaire was used every 2-4 years to assess participants’ diets over 30 years of follow-up.

Using the NOVA Food Classification system, the items on the food frequency questionnaire were categorized into one of four groups: unprocessed or minimally processed foods; processed culinary ingredients; processed foods; or UPFs, which were subdivided into nine mutually exclusive subgroups.

Servings per day were then used to determine individual UPF intake.

Higher total UPF intake was associated with a greater total energy intake, body mass index, and prevalence of hypercholesterolemia and/or hypertension, as well as lower healthy eating scores and physical activity.

The researchers calculated that, over 5,187,678 person-years of follow-up, there were 19,503 cases of type 2 diabetes across the three study cohorts.

Multivariate analysis taking into consideration a range of potential risk factors, including BMI, revealed that, across the three study cohorts, the highest quintile of UPF intake was associated with a significantly increased risk of type 2 diabetes.

Compared with the lowest quintile of UPF intake, the hazard ratio for incident type 2 diabetes was 1.28 (P < .0001), with an increase in risk per additional serving per day of 3%.

The UPFs associated with a higher type 2 diabetes risk were as previously described and also included animal-based products and ready-to-eat mixed dishes.

In contrast, intake of UPFs including cereals, dark and whole grain breads, packaged sweet and savory snacks, fruit-based products, and yogurt and dairy-based desserts were linked to a reduced risk of type 2 diabetes.

Then to further validate their findings, the researchers conducted a meta-analysis of their own and four additional studies, comprising 415,554 participants and 21,932 events, with a follow-up of 3.4-32.0 years.

They determined that the pooled relative risk of type 2 diabetes with the highest versus lowest levels of UPF consumption was 1.40, with each 10% increase in total UPF intake associated with a 12% increase in diabetes risk.
 

Ideal is to have access to minimally processed foods

The NOVA food classification system states that UPFs are industrial formulations “made mostly or entirely with substances extracted from foods, often chemically modified, with additives and with little, if any, whole foods added.”

A recent study questioned the value of the NOVA classification after finding that it had “low consistency” when assigning foods.

Previous studies have nevertheless revealed that UPFs and their constituents negatively affect the gut microbiota and can cause systemic inflammation, insulin resistance, and increased body weight.

Dr. Drouin-Chartier concluded: “There is a need to facilitate ... access to minimally processed foods. This encompasses [appropriate] pricing and physical access [to such foods], that is, addressing the issue of food deserts.”

The NHS I and II and HPFS studies are supported by National Institutes of Health. Dr. Drouin-Chartier has reported a relationship with the Dairy Farmers of Canada. No other financial relationships were declared.

A version of this article first appeared on Medscape.com.

High total intake of ultraprocessed food (UPF) is associated with an increased risk of developing type 2 diabetes, suggests a large-scale analysis that nevertheless revealed that the risk applies only to certain such foods.

Courtesy National Cancer Institute

The research was recently published in Diabetes Care by Zhangling Chen, PhD, Erasmus MC Rotterdam, Netherlands, and colleagues.

Examining almost 200,000 participants in three U.S. studies, yielding more than 5 million person-years of follow-up, the scientists found that high intake of UPF was associated with a 28% increased risk of type 2 diabetes, after statistical adjustments.

However, the increased risk was restricted to certain UPFs, including ready meals, refined breads, sweetened beverages, and sauces and condiments, with other foods considered UPFs, such as cereals, dark- and whole grain breads, and packaged sweet and savory snacks, among others, associated with a reduced risk of diabetes.

Senior author Jean-Philippe Drouin-Chartier, PhD, Nutrition Center, Laval University, Quebec City, told this news organization: “While whole grain breads can be considered as ultraprocessed foods, their consumption should not be discouraged. In our study, we observed that whole grain breads consumption is inversely associated with type 2 diabetes risk. This is supported by many studies linking dietary fiber consumption to better cardiometabolic health.”
 

Ultraprocessed food intake higher in the U.S. than in Europe

The researchers note that a handful of European studies have also reported an association between UPF consumption and increased type 2 diabetes risk, with the effect ranging from 15% to 53%, depending on the level of intake and the cohort of patients studied.

They note, however, that total UPF intake in the U.S. is “much higher than in Europe,” particularly in the case of ultraprocessed breads and cereals and artificially or sugar-sweetened beverages.

In the current study, they examined data on 71,781 women from the Nurses’ Health Study, 87,918 women from the NHS II, and 38,847 men from the Health Professional Follow-up Study, none of whom had cardiovascular disease, cancer, or diabetes at baseline.

In all three studies, questionnaires were administered every 2 years to collect demographic, lifestyle, and medical information, and a validated food frequency questionnaire was used every 2-4 years to assess participants’ diets over 30 years of follow-up.

Using the NOVA Food Classification system, the items on the food frequency questionnaire were categorized into one of four groups: unprocessed or minimally processed foods; processed culinary ingredients; processed foods; or UPFs, which were subdivided into nine mutually exclusive subgroups.

Servings per day were then used to determine individual UPF intake.

Higher total UPF intake was associated with a greater total energy intake, body mass index, and prevalence of hypercholesterolemia and/or hypertension, as well as lower healthy eating scores and physical activity.

The researchers calculated that, over 5,187,678 person-years of follow-up, there were 19,503 cases of type 2 diabetes across the three study cohorts.

Multivariate analysis taking into consideration a range of potential risk factors, including BMI, revealed that, across the three study cohorts, the highest quintile of UPF intake was associated with a significantly increased risk of type 2 diabetes.

Compared with the lowest quintile of UPF intake, the hazard ratio for incident type 2 diabetes was 1.28 (P < .0001), with an increase in risk per additional serving per day of 3%.

The UPFs associated with a higher type 2 diabetes risk were as previously described and also included animal-based products and ready-to-eat mixed dishes.

In contrast, intake of UPFs including cereals, dark and whole grain breads, packaged sweet and savory snacks, fruit-based products, and yogurt and dairy-based desserts were linked to a reduced risk of type 2 diabetes.

Then to further validate their findings, the researchers conducted a meta-analysis of their own and four additional studies, comprising 415,554 participants and 21,932 events, with a follow-up of 3.4-32.0 years.

They determined that the pooled relative risk of type 2 diabetes with the highest versus lowest levels of UPF consumption was 1.40, with each 10% increase in total UPF intake associated with a 12% increase in diabetes risk.
 

Ideal is to have access to minimally processed foods

The NOVA food classification system states that UPFs are industrial formulations “made mostly or entirely with substances extracted from foods, often chemically modified, with additives and with little, if any, whole foods added.”

A recent study questioned the value of the NOVA classification after finding that it had “low consistency” when assigning foods.

Previous studies have nevertheless revealed that UPFs and their constituents negatively affect the gut microbiota and can cause systemic inflammation, insulin resistance, and increased body weight.

Dr. Drouin-Chartier concluded: “There is a need to facilitate ... access to minimally processed foods. This encompasses [appropriate] pricing and physical access [to such foods], that is, addressing the issue of food deserts.”

The NHS I and II and HPFS studies are supported by National Institutes of Health. Dr. Drouin-Chartier has reported a relationship with the Dairy Farmers of Canada. No other financial relationships were declared.

A version of this article first appeared on Medscape.com.

High total intake of ultraprocessed food (UPF) is associated with an increased risk of developing type 2 diabetes, suggests a large-scale analysis that nevertheless revealed that the risk applies only to certain such foods.

Courtesy National Cancer Institute

The research was recently published in Diabetes Care by Zhangling Chen, PhD, Erasmus MC Rotterdam, Netherlands, and colleagues.

Examining almost 200,000 participants in three U.S. studies, yielding more than 5 million person-years of follow-up, the scientists found that high intake of UPF was associated with a 28% increased risk of type 2 diabetes, after statistical adjustments.

However, the increased risk was restricted to certain UPFs, including ready meals, refined breads, sweetened beverages, and sauces and condiments, with other foods considered UPFs, such as cereals, dark- and whole grain breads, and packaged sweet and savory snacks, among others, associated with a reduced risk of diabetes.

Senior author Jean-Philippe Drouin-Chartier, PhD, Nutrition Center, Laval University, Quebec City, told this news organization: “While whole grain breads can be considered as ultraprocessed foods, their consumption should not be discouraged. In our study, we observed that whole grain breads consumption is inversely associated with type 2 diabetes risk. This is supported by many studies linking dietary fiber consumption to better cardiometabolic health.”
 

Ultraprocessed food intake higher in the U.S. than in Europe

The researchers note that a handful of European studies have also reported an association between UPF consumption and increased type 2 diabetes risk, with the effect ranging from 15% to 53%, depending on the level of intake and the cohort of patients studied.

They note, however, that total UPF intake in the U.S. is “much higher than in Europe,” particularly in the case of ultraprocessed breads and cereals and artificially or sugar-sweetened beverages.

In the current study, they examined data on 71,781 women from the Nurses’ Health Study, 87,918 women from the NHS II, and 38,847 men from the Health Professional Follow-up Study, none of whom had cardiovascular disease, cancer, or diabetes at baseline.

In all three studies, questionnaires were administered every 2 years to collect demographic, lifestyle, and medical information, and a validated food frequency questionnaire was used every 2-4 years to assess participants’ diets over 30 years of follow-up.

Using the NOVA Food Classification system, the items on the food frequency questionnaire were categorized into one of four groups: unprocessed or minimally processed foods; processed culinary ingredients; processed foods; or UPFs, which were subdivided into nine mutually exclusive subgroups.

Servings per day were then used to determine individual UPF intake.

Higher total UPF intake was associated with a greater total energy intake, body mass index, and prevalence of hypercholesterolemia and/or hypertension, as well as lower healthy eating scores and physical activity.

The researchers calculated that, over 5,187,678 person-years of follow-up, there were 19,503 cases of type 2 diabetes across the three study cohorts.

Multivariate analysis taking into consideration a range of potential risk factors, including BMI, revealed that, across the three study cohorts, the highest quintile of UPF intake was associated with a significantly increased risk of type 2 diabetes.

Compared with the lowest quintile of UPF intake, the hazard ratio for incident type 2 diabetes was 1.28 (P < .0001), with an increase in risk per additional serving per day of 3%.

The UPFs associated with a higher type 2 diabetes risk were as previously described and also included animal-based products and ready-to-eat mixed dishes.

In contrast, intake of UPFs including cereals, dark and whole grain breads, packaged sweet and savory snacks, fruit-based products, and yogurt and dairy-based desserts were linked to a reduced risk of type 2 diabetes.

Then to further validate their findings, the researchers conducted a meta-analysis of their own and four additional studies, comprising 415,554 participants and 21,932 events, with a follow-up of 3.4-32.0 years.

They determined that the pooled relative risk of type 2 diabetes with the highest versus lowest levels of UPF consumption was 1.40, with each 10% increase in total UPF intake associated with a 12% increase in diabetes risk.
 

Ideal is to have access to minimally processed foods

The NOVA food classification system states that UPFs are industrial formulations “made mostly or entirely with substances extracted from foods, often chemically modified, with additives and with little, if any, whole foods added.”

A recent study questioned the value of the NOVA classification after finding that it had “low consistency” when assigning foods.

Previous studies have nevertheless revealed that UPFs and their constituents negatively affect the gut microbiota and can cause systemic inflammation, insulin resistance, and increased body weight.

Dr. Drouin-Chartier concluded: “There is a need to facilitate ... access to minimally processed foods. This encompasses [appropriate] pricing and physical access [to such foods], that is, addressing the issue of food deserts.”

The NHS I and II and HPFS studies are supported by National Institutes of Health. Dr. Drouin-Chartier has reported a relationship with the Dairy Farmers of Canada. No other financial relationships were declared.

A version of this article first appeared on Medscape.com.